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HomeMy WebLinkAboutMajor Mod Permit App 8-11-16UNDERGROUND STORAGE TANK COMPLETION DATE �_.__. _ �_.. 8_ RSFI _D, mPERMIT APPLICATION FIRE 4ARrm, r TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW TYPE OF BUSINESS TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD TANK OWNER Permit # ADDRESS � � ^ �n CITY U13 BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661- 326 -3979 • Fax: 661 -852 -2171 Page 1 of 1 TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY ir•uier•v r\nic nnaa vN rZd MnnTGTrA-rTrw nG PArTi TTv n MTNnR Mnr1TFTrATT0N OF FAC71 TTY STARTING DATE/ PROPOSED COMPLETION DATE FACILITY NAME �j _ EXISTING FACILITY PERMIT # FACILITY ADDRESS 700 /�//J G�r CITY ..� ZIP CO TYPE OF BUSINESS APN # TANK OWNER PHONE # ADDRESS � � ^ �n CITY U13 ZIP kn� CONTRACTOR (�hi1i��,~1�"'0�'►`� i�Ni.��.5��t `�� t.._aC�n. � —i�.. A'�� - CA LICENSE # ! ICC #���' ADDRESS Cr ZIPIVCQ -- PHONE # r �� � 00"d leK a BAKERSFIELD CITY BUSIN S LICENSE # L = WORKMANS COMP # �r.,sr .�- g INSURER BRIEFLY DESCRIBE THEE WORK TO BE DONE: '��_ ,� � :'Or +�-� • QU ` 1'�. � a 9 "A 1/�a iA cs — i L.� -� i �C .�A T! V . 90 ! I6' .5 WATER TO FACILITY PROVIDED BY DEPTH TO GROUND WATER � 1 I -}r, ��_ — SOIL TYPE EXPECTED AT SITE # OF TANKS TO BE INSTALLED 115) ARE THEY FOR MOTOR FUEL? IE!p YES ❑ NO SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? V1 YES ❑ NO THIS SECTION IS FOR STORAGE TANK IDENTIFICATION TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER TANK MANUFACTURER 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 APPROVED BY