HomeMy WebLinkAboutMinor Mod Permit App 9-14-16UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
IPermit# I
BAKERSFIELD FIRE DEPARTMENT
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
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❑ NEW TANK INSTALL/EXISTING FACILITY
r-21' MTKIOP mr)nTFT(-ATTON r)F FA( TI TTY
STARTING DATE/
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Prevention services
FACILITY NAMZ _,
2101 H Street
8 E R S F 1 0
-- ----- - ---- I ------
FIRE
Bakersfield, CA 93301
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Phone: 661-326-3979 • Fax: 661-852-2171
APN # C)
Page 1 of I
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
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❑ NEW TANK INSTALL/EXISTING FACILITY
r-21' MTKIOP mr)nTFT(-ATTON r)F FA( TI TTY
STARTING DATE/
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PROPOSED COMPLETION DATE
FACILITY NAMZ _,
EXISTING FACILITY PERMIT #
FACILITY ADDRESS
4
ZIP -CODE
0&-
TYPE OF BUSINESS ii
APN # C)
TANK OWNER
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PHONE # 661- 3Z7-%sq/
ADDRESS ` (�
CT ,
ZIP CODE
I
CONTRACTOR
CONTRA V(- 1
1ev
Ct , 51-A-Le 12
LICENSE #
CA "
C-7 1447--A,
ICC #
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ADDRESS
61
CITY
ZIP C 7E
2
PHONE #
ee I Z—
BAKERSFIELD CITY BUSINESS LICENSE #
WORKM NS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
14 C4- S vs
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
I
ARE THEY FOR MOTOR FUEL?
I)K YES ❑ NO gk
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # =
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER,
TANK MANUFACTURER
Tank Testing Company
NAME OF ESTING OMPANY
PHONE NUMBER YO? 2—
MAILING ADDRESS
e 0
,NAME OF TESTER
IC& 0 &-3
THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS
PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER
PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER
ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY