HomeMy WebLinkAboutUST-APPL. 8/18/2014L • I DWI to ' /
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
❑ NEW TANK INSTALL /EXISTING FACILITY
WATER TO FACILITY PROVIDED BY
I 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 Testing Company
NAME OF TESTING COMPANY Q SSR INC, C, PHONE NUMBER 66_588_2777
MAILING ADDRESS G3 1 V l�
6630 ROSEDALE HWY #B
NAME OF TESTER FIDEL CARRILLO ICC# 5257282
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 PER7URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICC#
FIDEL CARRILLO I 5257282
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED - APPROVED BY
FD2086 (Rev 08/09)