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HomeMy WebLinkAboutUST-APPL 2/9/2015UNDERGROUND STORAGE TANK PERMIT APPLICATION TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD IPermit # TYPE OF APPLICATION: FIRE BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661-326-3979 • Fax: 661-852-2171 Page 1 of 1 ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY n K4nnT[:T1-A-F-Tnh1 f_AC n'AJ-TI -- ---e - STARTING DATE/ X 1112.1mw­ i -Luim ur r-mi—L u i y PROPOSED COMPLEiION DATE FACILITY NAME 17 EXISTING FACILITY PERMIT # FACILITY ADDRESS C Z CODE TYPE OF BUSINESS APN # TANK OWNER PHONE # ADDRESS C ZIP-CODE 12kfd� 1 CONTRACT CA L -LIC-ENSE # ICC # ADDRESS W.CODE PHONE # BAKERSFIELD CITY BUSINESS LICENSE # WpKMANS COMP # J=URER BRIEFLY DESCRIBE THE WORK TO BE DONE: WATER TO FACILITY PROVIDED BY,,� C, xe DF,PT14 TO GROUND WATER SOX-lWPE EXPECTED AT SITE # OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? 0 YES © NO YES E3 NO 1H0 �E 1_711�""I.' ID V,11,�. 31., 10? 1',' F Z. TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER NAME OF TESTING COMPANY PHONE NUMBER MAILING ADDRESS NAME OF TESTER 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* AID ge THIS APPLICATION BECOMES A PERMIT WHEN APPROVED FOR OFFICIAL USE ONLY DATE APPROVED 21 115— APPROVED BY 9 ru4U00 tKev vts/uy) UNDERGROUND STORAGE TANK PERMIT APPLICATION TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY) /NEW TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD Permit # TYPE OF APPLICATION: BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661-326-3979 * Fax: 661-852-2171 Page 1 of 1 ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY M KAnnT[:Tr-A-rTf-%ft1 f-%r- 1 -A.-T1 STARTING DATE/ i iul%j ut- I-ACIM-Y -PROPOSED COMPLETION DATE /—? FACILITY NAME EXISTING FACILITY PERMIT # FACILITY ADDRESS C TYPE OF BUSINESS APN # TANK OWNER PHONE ADDRESS C ZIP r IDE CONTRACT 02— CA LIONSE # ICC - # ADDRESS CODE [PHONE # BAKERSFIELD CITY BUSINESS LICENSE # WORKMANS COMP # JUSURER BRIEFLY DESCRIBE THE WORK TO BE DONE: WATER TO FACILITY PROVIDED BY DEPT,N TO GROUND WATER S9X–WPE EXPECTED AT SITE # OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? ❑ YES ❑ NO Ar YES ❑ NO TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER Tiand&'..z, 15psthnq NAME OF TESTING COMPANY PHONE NUMBER MAILING ADDRESS NAME OF TESTER 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 TESTER ICC# All THIS APPLICATION BECOMES A PERMIT WHEN APPROVED FOR OFFICIAL USE ONLY DATE APPROVED APPROVED BY 2- Icl ru4woo (Kev UO/VV)