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11AWERSFIELD FIRE DOS'AORTMENT
Prevention Services
1600 Truxtun Ave., Suite 401
Bakersfield, CA 93301
Phone: 661-326-3979 * Fax: 661-852-2171
Page 1 of I
TYPE OF APPLICATION.- ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/B(ISTING FACILITY
(CHECK ONE ONLY) We"m"ODIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACILITY
R
STARTING DATE/ O '16POSED.COMPLETIO,N DATE
FACILITY NAME EXISTING FACILITY PERMIT #
FACILITY ADDRESS Z-1 CODE
TYPE OF BUSINESS APN
TANK OWNER
I PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR
]CA
LICENSE
ICC.#
10
ADDRESS
ZIP CODE
P 0
HONE4
BAKERSFIELD CITY: BUSINESS LICENSE
WORKMANS CO - Mp #
INSdRERT
BRIEFLY DESCRIBE THE WORK TO BE DONE:
L
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 1 ❑ YES ❑ NO
THIS SECTION IS FO MOTOR FUEL STORAGE TANKS I
FOR OFFICIAL USE ONLY
APPLICATION:OATF- FACILITY # # OF TANKS FEES $
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.
APPROVED BY APPLICANT NAME (PRINT) U PPLICANT SIGNATUR-
T
FD2086 (Rev 06/07)