HomeMy WebLinkAboutUST APPL 3/25/2014Permit #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661- 326 -3979 • Fax: 661 -852 -2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
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STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAME
EXISTIN FACILITY OERMIT #
FACILITY ADDRESS � CITY
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ZIP CODE
TYPE OF BUSINESS
Hes i at
APN #
TANK OWNER
PHONE # ^� ^ q
ADDRESS � Lr�+ ` �
CITY, � ""
ZIP CODE
CONTRACTOR j'
CA�LICENSE # `
ICC j�
ADDRESS
CITY ° Ad
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ZIPP CODE :.
PHONE #
661, 67Q -mss'
BAKERSFIELD CITY BUSINE S LICENSE #
4 0666145-
WORKMANS COMP #
INSURER
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BRIEFLY DESCRIBE THE WORK TO BE DONE:
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WAT R TO•F ILITY PRO DE BY
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DEPTH TO GROUND WATER
.5 6) '
SOIL TYPE EXPECTED AT SITE�a
# OF TANKS TO BE INSTALLED
4fi
ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
SPILL PREVENTION CONTROL ANDc6UNTERMEASURES PLAN ON FILE?
A YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER.
Tank Testing Company
NAME OF TESTING COMPANY
0��8 Ct - - ✓s '
PHONE NUTABER
6 ! - (f -
MAILING ADDRESS
NAME OF TEST R °,
ICC# Zqz 74 47
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 PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER_ 1, w
ICC# ;a
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED .—
APPROV
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