HomeMy WebLinkAboutMinor Mod Permit App 12-13-16UNDERGROUND STORAGE TANK '�P
PERMIT APPLICATION
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TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW FIRM
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD R��
Permit # /5'°- /00 Cwy l'
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
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/ _ PRO POSED.COMPLETION DATE
FACILITY NA:' "tc EXISTING FACILITY PERMIT #.
FACILITY ADDRESS A � CITY � S f� %� ZIP CODE
TYPE OF BUSINESS , APN # 0. j
TANK OWNER PH ^. NE #
1
WATER TO F.:(wILITY PROVIDED BY
DEPTH TO GROUND WATER I SOIL TYPE EXPECTED AT SITE
NAME OF TESTING COMPANY
MAILING ADDRESS
NAME OF TESTER
PHONE NUMBER
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 I ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED. -
APPROVED BY'
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FD2086 (Rev 08/09)