HomeMy WebLinkAboutUST-APPL. 11/17/20149 •
PERMIT APPLICATION
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
IPermit #
B `ERSP1c LIB
FIR#
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................
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BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661-326-3979 • Fax: 661-852-2171
Page I of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/ EXISTING FACILITY
(CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLET D Iq
FACILITY NAME '�_ 1 —"_7 1 EXISTING FACILITY PERMIT #
FACILITY ADDRESS CI Tr.-% ZIP COD
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TYPE OF BUSINESS APN #
TANK OWNER PHONE # 2
ADDRESS ZIP
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CONTRACTOR CA LICENSE
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ADDRESS CITY` r ZIP 0
PHONE # BAKERSFIELD BUSINESS LICENSE # WOR A S M # IWURER
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BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK ;IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank -resting Company
NAME OF TESTING ��S , -7 PHONE NUM
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MAILING ADDRESZ,,.
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NAME OF TESTS� C \j ICC#
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 TESTS ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)