HomeMy WebLinkAboutMinor Mod Permit App 12-29-16WATER TO FACILITY PROVIDED BY
SOIL TYPE EXPECTED AT SITE
DEPTH TO GROUND WATER
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO O YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK'# VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY q ONE NUMBER �/7
t ( Q
MAILING ADDRESS
�n_ LP 967
NAME OF TESTER ICC#
, �affln_ Ak- -1 'A k 0- L4 to co s
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 PER7URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICC# ( ..-
z
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPR01/ED BY
FD2086 (Rev 08/09)
BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
Prevention Services
Avenue, 1st Floor
1501 Truxtun
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NOMINE��4.;, , > -p �,.,,." � :..s _,�..._ _ .. �,.,M B
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Bakersfield, CA 93301
PPPLICATION
Phone: 661 -326 -3979 • Fax: 661 -852 -2171
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
page 1 of 1
;Perm it #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑
NE.W--TANK-II4SFA6L_ E_XI IN TG` FACILTTY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY
MINOR MODIFICATION OF FACI
STARTING DATE/ PROPOSED COMPL
TE
EXISTING FACILITY PERMIT #
FACILITY NAME
<ay'� Q
0,
CITY
ZIP CODE
FACILITY ADDRESS t 11111111111
APN #
TYPE OF BUSINESS
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PHONE #
TANK OWNER
ADDRESS
CITY
ZIP CODE
:CONTRACTOR
CA ENE
ICC
CITY
ZIP CqQ
ADDRESS
PHONE BAKERSFIELD CITY BUSINESS LICENSE #
r
WORKMANS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY
SOIL TYPE EXPECTED AT SITE
DEPTH TO GROUND WATER
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO O YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK'# VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY q ONE NUMBER �/7
t ( Q
MAILING ADDRESS
�n_ LP 967
NAME OF TESTER ICC#
, �affln_ Ak- -1 'A k 0- L4 to co s
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 PER7URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICC# ( ..-
z
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPR01/ED BY
FD2086 (Rev 08/09)