HomeMy WebLinkAboutUST-APPL. 11/24/2014q
PERMIT APPLICATION
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
IPermit # I11,1n5t-0 5-'-j9LI
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(r,wr-r,v nNip: r)r\ii v) m mr)nT1=TrATTC)N OP FAMI TTY VP MTNnp mnr)TFT(-ATTnNnF FACTI TTY
STARTING DATE/ PROPOSED
BAKERSFIELD FIRE DEPARTMENT
FACILITY NAME oq
Prevention Services
_4
2101 H Street
B_ ACW-_. E R S F L D
Bakersfield, CA 93301
FIRE
Phone: 661-326-3979 • Fax: 661-852-2171
TANK OWNER u
PHONE #
Ri
Page I of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(r,wr-r,v nNip: r)r\ii v) m mr)nT1=TrATTC)N OP FAMI TTY VP MTNnp mnr)TFT(-ATTnNnF FACTI TTY
STARTING DATE/ PROPOSED
COMPLETION DATE
FACILITY NAME oq
EXISTING FACILITY PERMIT
FACILITY ADDRESI
Cl
CITY
ZIP 7
TYPE OF BUSINE
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tio C�� - r-c"t C ti
APN #
TANK OWNER u
PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR:? C
CA LICENSE #
ICC,
ADDRESS 'o-1
U �404J
ZIPM-2
PHONE #
BAKERSFIELD CITY BUY LICENSE #
1 Q:2 QL
WORKMANS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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cz�v_r.)54_ �' Qkl� -Or r1+_L
=12f-5 X, rXV II <_
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL?
1 ❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THEE SECTION ES FOR STORAGE TANK EDEN7EFICATETON
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME "PA -7
=�_IbG
PHONE NUMBER
_7`7 -7)
MAILING ADDRESS R
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NAME OF-USTkR 'M
+_14
ICC# del
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#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED IIb"e1 11 1-'
APPROVED BY -,)nor /D_ nolf)a"