HomeMy WebLinkAbout1200 coffee major forms 12-20-16_1-4BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
2101 H Street
0i"RMIT APPLICATION B E R 3 B I D Bakersfield, CA 93301
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW «I Phone: 661 - 326 -3979 •Fax: 661 - 852 -2171
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD wRf// T
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Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
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STARTING DATE/ PROPOSED
10/20/2016 11/20/2016
COMPLETION DATE
FACILITY NAME
Fastrip Food Store 1
EXISTING FACILITY PERMIT #
15- 021 -03504
FACILITY ADDRESS
1200 Coffee Road
CITY
Bakersfield
ZIP CODE
93308
TYPE OF BUSINESS
C -Store / Gas Station
APN #
'
TANK OWNER
Jamieson Hill
PHONE #
661- 393 -7000
ADDRESS
PO Box 82515
CITY
Bakersfield
ZIP CODE
93380
CONTRACTOR
Jaco Oil Company (Matthew Cheney)
CA LICENSE #
1970529
ICC #
8129033
ADDRESS
PO Box 82515
CITY
Bakersfield
ZIP CODE
93380
PHONE #
661- 868 -9484
BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
WC3486600
INSURER
American Zurich Ins. Co.
BRIEFLY DESCRIBE THE WORK TO BE DONE:
Excavate Around Premium Tank Annular Riser to make necessary repairs in order to achieve 10inches Hg vacuum
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
0
ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
X YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTING COMPANY
Jaco Oil
PHONE NUMBER 661- 633 -7508
MAILING ADDRESS
PO Box 82515 Bakersfield, CA 93380
NAME OF TESTER
Matt Cheney
ICC#
812933
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
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