HomeMy WebLinkAboutMinor Mod Permit App 1-6-17BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
B: E R S F 1 D 2101 H Street
PERMIT APPLICATION' �+� Bakersfield, CA 93301
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TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW Phone: 661- 326 -3979 • Fax: 661 -852 -2171
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD "'�'�
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Permit #` 6 r'
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY INOR MODIFICATION OF FACILITY
STA T G D TE/ PROPOSED COMPLEfION DATE
FACI NAME EXISTING FACILITY PERMIT #
FACI E5S CI Z
Lkg:�4j TYPE USIN S APN #
TANK OWNER PHONE #
ADDRESS CITY ZIP CODE
CON R QAr GA NS ## ICC #
ADDFPESS. ' t CI ZIP
PHONE BAKERSFI CITY BUSINESS LICENSE # WORKMANS COMP # INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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WATER TO FACILITY PROVIDED BY
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?
❑ YES ❑ NO ❑ YES ❑ NO
THIS S[EC71ON IS FOR STORAGE TANK IDENTIFECATI.ON
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER TANK MANUFACTURER
Tank Testing Company
NAME F STIN COMPANY PHON N MBER
e. MAILIJIIG ADDRESS
NAM STER ICC
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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,0E-MSTF4t f ICC#
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 11/2015)