HomeMy WebLinkAbout[Untitled]_15-58A
KERN COUNTY ENVIRONMENTAL HEALTH SERVICES DEPARTMENT
2100 W STREET, SUITE 300
BAKERSFIELD, CA 93301
(805) 861 -3536
TWMkyAL USE ONLY:
PTO _ U PTA # 9
APPLICATION DATE
S OF TANKS TO BE ABANDONED
LENGTH Or PIPING TO ABANDON
APPLI CAT= ON FfJR PERMZ T FC]R PERMANENT
CLOSURE /ASANDONMEN'T OF UNDERGROUND
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THIS APPLICATION IS FOR RE}IOVAL. OR Q AItAN00N?t£HT IN PLACE (FILL OUT ONE APPLICATION PER FACILITY) _
PROJECT CONTACT PHONE SEC /TlR (RURAL LLiGt2I0HS-ONLY!
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TANK REMOVAL CONTRACTOR
ADDRESS
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CHEMICAL COMPOSITION OF MATERIALS STORED
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CHEMICAL PREVIOUSLY STORED
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WATER TO PA 'CITY PROVIDD BY
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NEAREST WATER WELL - GIVE DISTANCE AND D CRIBE 'TYPE IF WITHIN $00 FEET
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BASIS FOR SOkL TYPE AND GR�Or, UNDWATER DEPTH ET_ ERWHAT N
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TOTAL NUMBER 0P ANALYZED
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ESCRIBE HOW RESI E IN TANKI I AND PIPING TO E REMOVED D POSE 0 (INCLUDE TRANSP AT N
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ESCRIBE BOTH THE DISPOSAL TIIOD AND DISPOSAL L04ATION FOR: ��������lea iI ��
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THIS !ORP .%A%; DES PCETED ER EN ^ 7 PER AND It BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
DATE
SIGNATURE'
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