HomeMy WebLinkAboutUST-PERMIT APPL 12/9/2015BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
1501 Truxtun Avenue, 11t Floor
PERMIT APPLICATION y �.�.. Bakersfield, CA 93301
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW pisE Phone: 661 -326 -3979 •Fax: 661 - 852 -2171
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD Rrz T
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Page 1 of 1
;Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLETION DATE
FACILITY NAME o EXLS'TING FACILITY PERMIT #
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FACILITY ADDRESS ZIP CODE
TYPE OF BUSINESS � APN #
TANK OWNER
PHONE #
ADDRESS CTTY ZIP CODE
CONTRACTOR-----b CA LICENSE # ICC #
C .. 07
Q �` b
ADDRESS ZIP DE
PHONE l ' � ERSFIELD CITY .BUSINESS LICENSE* WORKMANS COMP # INSURER ®
BRIEFLY DESCRIBE THE WORK TO BE DONE:
L C 0%, r-010 ck'\` IkA 6
"v> >+L� `C-.� d�•iZ� �$ ...X� � 4.x..710 �d
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? FOSPIL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑. NO YES 0 NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK-* VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Z Cs ®�
3,
Tank Testing Company
NAME OF TESTING COMP PHONE NUMBER
MAILING ADDRESS
NAME OF TESTER Imo#
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 PER]URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME °f: TESTER ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED > APPROVED BY
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