HomeMy WebLinkAboutMinor Mod Permit App 4-26-16BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK %�� ,
Prevention Services
f r F� r a ri 2101 H Street
Bakersfield, CA 93301
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PERMIT APPLICATION a R s 3 r 3: Phpne: 661 - 326 -3979 •Fax: 661 -852 -2171
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW ? Al!'1'e1' f
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD page 1 of 1
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
CHECK ONE ONLY MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLETION DATE
03/31/2016 3/31/16
EXISTING FACILITY' PERMIT'#
FACILITY NAME
Sully's Coffee
FACILITY ADDRESS CITY ZIP CODE
6009 Coffee Road Bakersfield 93308
APN #
TYPE OF BUSINESS
GDF
PHONE #
TANK OWNER
Sully's Food Store LLC 661 - 327 -5008 CITY ZIP CODE
ADDRESS Bakersfield 93301
1000 Truxtun Avenue
�CA LICENSE # CC #
CONTRACTOR 8 04 9 04
Confidence UST Services Inc.
CITY ZIP CODE
ADDRESS
16250 Meacham Road Bakersfield INSURER
PHONE #' BAKERSFIELD CITY.BUSINESS LICENSE WORKMANS COMP # INSUURER
E
66'1 -631= 3870 32864 1308371, SCIF
BRIEFLY DESCRIBE THE WORK TO BE DONE:
Replace Veeder -Root 794380 -304 in Diesel Fuel Annular (L14).
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES NO YES NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
1 12000 x x
2 12000 x x
x
3 12000
Tank Teeing Company
NAME OF TESTING COMPANY PHONE NUMBER
Confidence UST Services Inc. 661 -631 -3870
MAILING ADDRESS
16250 Meacham Road, Bakersfield, CA 93314
ICC#
NAME OF TESTER
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 AND CORRECT.
UNDER
PENALTY OF PERJURY, AND TO THE BEST OF MY
ICC#
NAME OF TESTER 8111231 -UT
Bradley Seykora
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
APPROVED BY t
DATE APPROVED
FD2086 (Rev 08/09)