HomeMy WebLinkAboutMinor Mod Permit App 12-29-16BAKERSFIELD FIRE DEPARTMENT
Prevention Services
UNDERGROUND STORAGE TANK 1st Floor
1501 Truxtun Avenue, I
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S F I
D Bakersfield, CA 93301
PERMIT APPLICATION FIRK Phone: 661-326-3979 •Fax: 661-852-2171
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TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW
ARTS
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TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD Page 1 of I
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALLINEW FACILITY ❑ NEW TAN NG FACILITY
(CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACI
STARTING DATE/ PROPOSED COO
FACILITY NAME EXISTING FACILITY PERMIT #
FACILITY 1 1 zipff!!*kk
DRESS -�2 --�2 i r\ C) I%A v-\ /% Fr\ A/-.- /,i n 0 -?, I
TYPE OF BUSINESS i hp APN #
TANK OWNER Mo C/-
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
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❑ YES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK * VOLUME UNLEADED REGULAR. PREMIUM :DIESEL OTHER
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Tank Testing Company
NAME OF TESTING COMPANY-J:Z 1,0-kf% _1___aA i rt tr^ %A CAA A f/\ In PHONE NUMBER
MAILING ADDRESS d--'r p r -n n 1 ems. 4n I
NAME OF TESTER - a - -r-*) • ® 1, - I 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---T- ICC#
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)