HomeMy WebLinkAboutUST-APPL 12/9/2014UNDERGROUND STORAGE TANKS
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 will be Charmed per
separate type test accordingly.)
PERMIT #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
AfflEx S P I n 2101 H Street
SINK Bakersfield, CA 93301
ARTN' T Phone: 661- 326 -3979 • Fax: 661 -852 -2171
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❑ ENHANCED LEAK DETECTION ❑ LINE TESTING SB -989 SECONDARY CONTAINMENT
❑ TANK TIGHTNESS 0 FUEL MONITORING CERTIFICATION
SITE INFORMATION
FACILITY
Flower Street Mini mart..
NAME & PHONE # OF CONTACT PERSON
Hussain Monsour (661) 328 -0732
ADDRESS
928 Flower Street Bakersfield
OWNER NAME
Flower Street Mini Mart
OPERATOR NAME
Hussain Monsour
PERMIT TO OPERATE #
# OF TANKS TO BE TESTED:
IS PIPING GOING TO BE TESTED? ❑ YES ❑ NO
TANK #
VOLUME
CONTENTS
TANK TESTING COMPANY
TESTING COMPANY
Confidence UST Services Inc.
NAME & PHONE # OF CONTACT PERSON
Karli Karns (661) 631 -3870
MAILING ADDRESS
16250 Meacham Road Bakersfield CA 93314
NAME & PHONE # OF TESTER OR SPECIAL INSPECTOR
Bryan Self (661) 3-33-0000
CERTIFICATION #
B37501
DATE & TIME TEST TO BE CONDUCTED
12 12 13 at 9:00am
ICC #
8022804 -UT
TEST METHOD
APPLICANT SIGNATURE
DATE
Ici 5
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APP V:ED :BY e
DATE
FD209S (Rev 03/08)