HomeMy WebLinkAboutMinor Mod Permit App(CHECK ONE ONLY MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/
PROPOSED COMPLETION DATE
BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
NAME
FACILITY
EXISTING FA PERMIT
Prevention Services
A
2101 H Street
Bakersfield, CA 93301
PERMIT APPLICATION
M
2317 L Street
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NE W
TYPE OF BUSINESS
P lAff
ARTA► T
e
Phone: 661-326-3979 Fax: 661-852-2171
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
TANK OWNER
PHONE #
Page 1 of 1
IPermit #A6 -6n0M 6 3
-Sully's
ADDRESS
CITY
ZIP CODE
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
09/2312016
9/23116
NAME
FACILITY
EXISTING FA PERMIT
Sully's Downtown (South)
_]Zkersfield
FACILITY ADDRESS
ZIP CODE
193301
2317 L Street
TYPE OF BUSINESS
APN #
GDF
TANK OWNER
PHONE #
Food Store, LLC
(661) 327-5008
-Sully's
ADDRESS
CITY
ZIP CODE
1000 Truxtun Avenue
Bakersfield
93301
CPNTRA&6k�:
s,,. Inc
conf idenq&.� UST Services
GA LICENSE #�
8:0 , §�b 4
ICC #
8414476 -UT
7 ADDRESS A
16250 Meacham Road
'CITY
Bakersfield '33
,
ZIP CODE
9 14
'PHONE #
6AkERSFIELD CITY. BUSINESS LICENSE #
WORKMANS COMP #
1308371
INSURER
SCIF4
6 6 1 3 1'.. 3 �817 0,
2 8 6
3 :4::
BRIEFLY DESCRIBE THE WORK TO BE DONE:
Reolaced Veeder-Root Sump Sensor (MN 794380-208) in 87 STP Sump.
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# 8414476-UT
Tim Capehart
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)