HomeMy WebLinkAboutMinor Mod Permit App 1-28-16TYPE OF APPLICATION: ❑ NEW TANK INSTALLINEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY Vu MINOR MODIFICATION OF FACILITY
STARTjN ATE-j,, PROPOSED 'COMP ION DATE
FACILIP7Ej t EXISTING FACILITY PERMIT #
FACILI DRESS CI ZIP COD
TYPE OF
BAKERSFIELD FIRE DEPARTMENT
-
Prevention Services
2101 H Street
E E R s F F; i,
Bakersfield, CA 93301
FIRLF
Phone: 661- 326 -3979 s Fax: 661 -852 -2171
ADDRESS
Page 1 of 1
CITY
TYPE OF APPLICATION: ❑ NEW TANK INSTALLINEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY Vu MINOR MODIFICATION OF FACILITY
STARTjN ATE-j,, PROPOSED 'COMP ION DATE
FACILIP7Ej t EXISTING FACILITY PERMIT #
FACILI DRESS CI ZIP COD
TYPE OF
INESS
4
APN #
°
TANK
- i
PHONE #
ADDRESS
CITY
ZIP CODE
CONT
�
CA LICENSE
# �
'ICC #
ADDRESS
CI
vzm— a64(�-14
ZIP
PHONE #
B KERSFIELD CITY BUSINUS LICENSE #
WORKMANS
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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
THES SECTEON IS FOR S70€ AGE 7AMK ZDEM7ZFZC'17-710H
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank 7esUng Company
NAME OF&ESXA PA NY PHON E
L�
MAILING DDRES5
- ?.
NAME OF . R Icc# C �'j -T
_4C( C'y,[ JC) 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 I ICC##
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)