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Home My WebLink AboutMinor Mod Permit App 8-12-16UNDERGROUND STORAGE TANK PERMIT APPLICATION TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD Permit TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY (('HF('K C)NF nNI Y) n MODTFTCATTnN nF FACTI_TTY M MTNOR Mnr)TFTCATTON OF FACTI TTY STARTING DATE/ As soon as permit is issued. Costco Loc. 643 / BCE No. 11859 FACILITY NAME Costco Gasoline Loc. No. 643 BAKERSFIELD FIRE DEPARTMENT FACILITY ADDRESS 4900 Panama Lane Prevention Services ZIP CODE 93313 2101 H Street e e R s f 1 o TFIRE TANK OWNER Dennis Bock, Costco Wholesale PHONE # 425 313 -8100 Bakersfield, CA 93301 �RrM r Phone: 661 - 326 -3979 . Fax: 661 -852 -2171 CONTRACTOR WSK and Sons, Inc. 1888712 Page 1 of 1 TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY (('HF('K C)NF nNI Y) n MODTFTCATTnN nF FACTI_TTY M MTNOR Mnr)TFTCATTON OF FACTI TTY STARTING DATE/ As soon as permit is issued. PROPOSED COMPLETION DATE FACILITY NAME Costco Gasoline Loc. No. 643 EXISTING FACILITY PERMIT # CERS 10028320 FACILITY ADDRESS 4900 Panama Lane FBakersfield, California ZIP CODE 93313 TYPE OF BUSINESS Retail Fuel Facility APN # TANK OWNER Dennis Bock, Costco Wholesale PHONE # 425 313 -8100 ADDRESS P.O. Box 35005 CITY Seattle, Washington ZIP CODE 98124 CONTRACTOR WSK and Sons, Inc. 1888712 CA LICENSE # ICC # A26028 ADDRESS 34455 Sunlight Drive CITY Yucaipa, California ZIP CODE 92399 PHONE # (951) 906 -3023 BAKERSFIELD CITY BUSINESS LICENSE # 11600108086 WORKMANS COMP # 901918445 INSURER State Comp. Fund BRIEFLY DESCRIBE THE WORK TO BE DONE: Installation of Shroud Vent Box WATER TO FACILITY PROVIDED BY Public Municipality DEPTH TO GROUND WATER 90 feet SOIL TYPE EXPECTED AT SITE Silty Sand Medium Density # OF TANKS TO BE INSTALLED O ARE THEY FOR MOTOR FUEL? ❑ YES ❑ NO N/A SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? M YES ❑ NO THIS SECTION IS FOR S'T'ORAGE TANK IDENTIFICATION C xi5-r nJ rowt, —s —No e #,+A16E5 TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER TANK MANUFACTURER 1 30,000 X X Containment Solutions 2 30,000 X X Containment Solutions 3 30,000 X X Containment Solutions 4 1,500 Ultrazol Containment Solutions Tank Testing Company NAME OF TESTING COMPANY PHONE NUMBER MAILING ADDRESS NAME OF TESTER ICC# 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 j 2//� 1/16 APPROVED BY