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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)