HomeMy WebLinkAboutTank Integrity Permit App 1-3-17UNDERGROUND S'T'ORAGE 'TANKS
APPLICATION
TO PERFORM ELD /LINE TESTING/
SB989 SECONDARY CONTAINMENT
TESTING/TANK TIGHTNESS TEST AND
FUEL MONITORING CERTIFICATION
(please note that these are separate
Individual and
accordingly.)
Per
separate type tea
PERMIT #
❑ ENHANCED LEAK DETECTION
'TANK TIGHTNESS
R J •'
wf i
;.y O
FACILITY .
ADDRESS 0 ®`
OWNER NAME
n TOR NAM4E
T�k1� X TO BE TESTED:
TANK #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
14tm X- 1 akot k-k 5-mf—V--T
TJrJrAW Bakersfield, CA 93301
Phone: 661 -326-3979 a Fax: 661- 852 -2171
Page 1 of 1
❑ LINE TESTING ❑ SS-989 SECONDARY CONTAINMENT
FUEL MONITORING CERTIFICATION
® NAME & PHONE si' OF CONTACT PERSON
mm
Nw
f - 4
PERMIT TO OPERATE #
IS PIPING GOING TO BE TESTED? ❑ YES
VOLUME CONTENTS
NO
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, t
• 1'. :iH:1
y.
PERSON
AiAME''& PHONE #.O
F CONTACT
TESTING COMPANY
'
MAILING ADDRESSQ tvJ C.�" . '° ♦1 "�RS� `'�L''.O ♦ C �5
CERTIFICATION # C
NAME 8c PHONE # OF TESTER OR SPECIAL IN5PECTOR S ®9 8 Jc)
/'" -•� �C� ST METRO
y Icc
DATE & TIME TEST tb BE CONDUC 110 6%pyp�X 612
DATE
APPLt SIGNATURE
THIS APPL14CATION B.ECO14ES A PE' IT WHEN APPROVED
DATE
APPROVED BY
FD2095 (Rev 03/08)