HomeMy WebLinkAboutFMC Permit App 12-6-16UNDERGROUND STORAGE 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 tests and will he charged per
separate type test accordingly.)
PERMIT #
loop
B >£ R S F! D
FIRE
ARTAF F
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 -326 -3979 . Fax: 661 - 852 -2171
Page 1 of 1
❑ ENHANCED LEAK DETECTION ❑ LINE TESTING ❑ SB -989 SECONDARY CONTAINMENT
❑ TANK TIGHTNESS 0 FUEL MONITORING CERTIFICATION
SITE INFORMATION
FACILITY
ME e PHONE # OF CON -7CT P t ON b
ADDRE;
OWNER NAME
OPERATOR NAME ` %�
PERMIT TO OPERATE #
# OF TANKS TO BE TESTED:
IS PIPING GOING TO BE TESTED? YES ❑ NO
TANK #
VOLUME
CONTENTS
V o`✓`°"
TANK TESTING COMPANY.
TE C NTA T PERSON
�r c� ( NAME n0aNE#kE 0F CO
MAILING DRE ,.- ^' ^� -�%�
tyAME & PHONE # OF TESTER OR SPECIAL INSFPECq.Rk
CERTIFICATION # csGi�
DATE & jl TEET TO B C/ON�DUCTED
ICC #
TEST METHOD
APPLICANT SIG ATURE
DATE
LO
THIS APPLIC OMES A PERMIT WHEN APPROVED
APPROVED BY'
DATE
FD2095 (Rev 12/15)