HomeMy WebLinkAboutUST-APPL 11/26/2014UNDERGROUND STORAGE TANK
I 71 7: M-7
PERMIT APPLICATION
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
1-1 —.1 — —.1. X/N n hAt%r%TC7Tf'A-rTnft1 nC CArTl T-T-V
❑ NEW TANK INSTALL/EXISTING FACILITY
V MTK1r)Q mr)r)TFTr,&TTr)N r)F FArT1 T-ry
STARTING DATE/ PROPOSED
ij_-LL --114
BAKERSFIELD FIRE DEPARTMENT
FACILITY NAME , ,
Prevention Services
FACILITY ADDRESS -7
2101 H Street
. . . . . . . . . . 6 w Wr Y�
Bakersfield, CA 93301
FIRE
Phone: 661-326-3979 • Fax: 661-852-2171
R T
ADDRESS
7
V
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
1-1 —.1 — —.1. X/N n hAt%r%TC7Tf'A-rTnft1 nC CArTl T-T-V
❑ NEW TANK INSTALL/EXISTING FACILITY
V MTK1r)Q mr)r)TFTr,&TTr)N r)F FArT1 T-ry
STARTING DATE/ PROPOSED
ij_-LL --114
COMPLETION DATE
_7 _UA
FACILITY NAME , ,
xisI I NG. �MCI I LITY PE* II T I #
FACILITY ADDRESS -7
C
ZIP CODE
TYPE OF BUSINESS 0,
APN
TANK OWNER
lw,�A5
PHONE#
ADDRESS
7
crr
ZIP CODE
CONTRACTOR V\
CA LICENSE #
Llb
ICC #
.ADDRESS
6q 4 By'
CITY
ZIP CODE
7
PHONE #
BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
776
INSURE
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?
1 ❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTING COMPANY ;z za-
PHONE NUMBER
MAILING ADDRESS 62 '721_�
626 fig` 6 jz0 lzz�
NAME OF TESTER I 1\
6 s
ICC#
6
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
APPROVED BY
Fr)7nR6 (Rev nvog)