HomeMy WebLinkAboutUST APLLICATION 2/4/2015JNDERGROUND STORAGE TANKS
U w� w�v -gn - — — — - —, . - - - — - - "
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 wlig be charged per
separate type test accordingly.)
PERMIT # I /5-7/0000-i (0 /..]
❑ ENHANCED LEAK DETECTION ❑ LINE TESTING WIS—B-989 SECONDARY CONTAINMENT
❑ TANK TIGHTNESS ❑ FUEL MONITORING CERTIFICATION
SITE INFORMATION
FACILITY NAME & PHONE # OF CONTACT PERSON
ADDRESS -IZ Oti 'E Q I. Z>
OWNER NAME H015?io-CAL-
OPERATOR NAME I PERMIT TO OPERATE #
# OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? ' —YES ❑ NO
TANK # VOLUME CONTENTS
5;000 C�RLLOVQ S -t-- L
TANK TESTING COMPANY
TESTING COMPANY NAME & PHONE # OF CONTACT PERSON
. t
MAILING ADDRESS
NAME & PHONE * OF TESTER OR SPECIAL INSPECTOR CERTIFICATION # L1
TIORL-CAR'RILL0 66(-X-"5-a173 -
DATE &TIME TEST TO BE CONDUCTED ICC # TEST METHOD
5:R
- 5 -
APPLICANT SIGNATURE DATE
FD2095 (Rev 03/08)
BAKERSFIELD FIRE DEPARTMENT
s_11
Prevention Services
'84E P I D
2101 H Street
1priNj®r
Bakersfield, CA 93301
Phone: 661-326-3979 • Fax: 661-852-2171
Page I of I
❑ ENHANCED LEAK DETECTION ❑ LINE TESTING WIS—B-989 SECONDARY CONTAINMENT
❑ TANK TIGHTNESS ❑ FUEL MONITORING CERTIFICATION
SITE INFORMATION
FACILITY NAME & PHONE # OF CONTACT PERSON
ADDRESS -IZ Oti 'E Q I. Z>
OWNER NAME H015?io-CAL-
OPERATOR NAME I PERMIT TO OPERATE #
# OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? ' —YES ❑ NO
TANK # VOLUME CONTENTS
5;000 C�RLLOVQ S -t-- L
TANK TESTING COMPANY
TESTING COMPANY NAME & PHONE # OF CONTACT PERSON
. t
MAILING ADDRESS
NAME & PHONE * OF TESTER OR SPECIAL INSPECTOR CERTIFICATION # L1
TIORL-CAR'RILL0 66(-X-"5-a173 -
DATE &TIME TEST TO BE CONDUCTED ICC # TEST METHOD
5:R
- 5 -
APPLICANT SIGNATURE DATE
FD2095 (Rev 03/08)