HomeMy WebLinkAboutUST-APPLICATION 2/12/2015UNDERGROUND STORAGE TANK
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
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STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAME
Ke:rf% caj,-�4 �4.e MiA4e^ 6✓4- -.;l LAA 61) 0
EXISTING FACILITY PERMIT #
FACILITY ADDRESS
-705 -.5 - (j A I f) ^_
CITY
ZIP CODE 1
TYPE OF BUSINESS
APN #
TANK OWNER
k r^ L 4- 'A
PHONE # TAY g
ADDRESS
-7 v. T
CITY
;.6
ZIP CODE
4,5,30--)
CONTRACTOR
C,0r(— A-jje-,./
CA LICENSE #
q 1("D
icc #
i cx"31
ADDRESS f
C01144ur-6. All
CITY
"-�) 4tcz rs
ZIP CODE
rl 33 c) ti
PHONE #
60 52?
BAKERSFIELD CITY BUSINESS LICENSE #
Dou
WORKMANS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
..-Ii
4c--- Y-) &N (.),r,'T 114 w% +-or Lo%.- a • I A Cv^ _r f "St>
+--e-
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL
TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
a
ARE THEY FOR MOTOR FUEL? SPILL
❑ YES ❑ NO
PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTING COMPANY
n
C-A-1
PHON NUMBER
32-7 C7 S %-A I
MAILING ADDRESS
44 Or Al��e'A v CS e. Mo c6
NAME,OF TESTER
j� Er r�x
ICC*
I u,
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
ICC#
C) 10 H
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
_Ze7do
APPROVED BY
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