HomeMy WebLinkAboutMinor Mod Permit App 1-17-17BAKERSFIELD FIRE DEPARTMENT
�°i° TANK Prevention Services
UNDERGROUND
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2101 H Street
PERMIT APPLICATI ®N FIRE Bakersfield, CA 93301
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW gl�TM T phone: 661 -326 -3979 Fax: 661 - 852 -217
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD a
Page I of 1
Permit # 12 1O�WW 2
T'Y'PE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
(CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/ p PROPOSED COMPLETION DATE
FACILITY NAME
Or ® ` ® �^ EXISTING FACILITY PERMIT #
FACILITY ADDRESS 1 / '0' CITY ZIP CODE
Coy
TYPE OF BUSINESS 9 APN #
TANK OWNER PHONE #� r
ADDRESS CITY ZIP CODE
CONTRACTOR CA LICENSE # ICC #
ADDRESS ro aps � CITY ZIP CODE
PHONE # BAKERSFIELD CITY BUSINESS LICENSE # WORKMANS COMP # INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
4441Ve 4C=49
WATER TO FACILITY PROVIDED BY
b
DEPTH TO GROUND WATER y SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED �pr ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
P' 113 YES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER TANK MANUFACTURER
TanOc Testing Company
NAME OF TESTING COMPANYjf PHONE NUMBER
MAILING ADDRESS Pl°"
NAME AE' TESTER
gr 1y�` ICC# 0 sy
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 SEEN COMPLETED UNDER
PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER /X/ ICC# ,^„el g
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 11/2015)