HomeMy WebLinkAboutFMC Permit App 1-3-17UNDERGROUND STORAGE TANKS
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3A 123 KERSFIELD FIRE DEPARTMENT
Prevention Services
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A WE 2-8 D
F
APPLICATION
Bakersfi61d, CA 93301-
TO PERFORM ELD/LINE TESTING/
*A
Phone: 661-326-3979 • Fax: 661-852-2171
SB989 SECONDARY CONTAINMENT
Page I of 1
TESTING/TANK TIGHTNESS TEST AND
FUEL MONITORING CERTIFICATION
(Please note that these are separate
individual tests and will be charged per
separate type test accordingly.)
PERMIT #
❑ ENHANCED LEAK DETECTION
❑ LINE TESTINI--
❑ SB-989 SECONDARY CONTAINMENT
❑ TANK TIGHTNESS
�EL. MONITORING CERTIFICATION
FACILITY
NAME & PHONE # OF CONTACT PERSON
ADDRESS
NYC
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OWNER NAME
OPERATOR NAME
I PE, RMIT TO OPERATE #
# OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? ❑ YES ❑ NO
TANK * VOLUME CONTENTS
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TESTING COMPANY NAME & PHONE # OF CONTACT PERSON
PAM
MAILING ADDRESS
5LeL-k � t > f W 0 C% CX -
NAME & PHONE .# OF TESTER OR SPECIAL INSPECTOR CERTIFICATION #
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DATE & TIME TEST 'rO-BE CON- -- ICC TEST METHOD
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SIG I , & I
APPLI TUBE DATE
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APPROVED BY I DATE
FD209S (Rev 03/08)