HomeMy WebLinkAboutUST-APPL 5/28/2014BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
1501 Truxtun Avenue 1st Floor
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PERMIT APPLICATIONa Bakersfield, CA 93301
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW: EIl� Phone: 661 - 326 -3979 •Fax: 661 - 852 -217].
TANK INSTALL (EXISTING FACI AtT�I l
FACILITY)/MOD-MINOR MOD ' W;
Page 1 of 1
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAM
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EXISTING FACILITY PERMIT #
FACILITY ADDRES ` CiIY ZIP 4: D,l
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TYPE OF BUSINESS APN #
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TANK OWNER
PHONE # ✓�.
ADDRESS
CITY
ZIP CODE
CONTRACTO ,
CA LICENSE #
ICC #
ADDRESS.
ZIP CODE
PHONE # g
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BAKE FIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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V Z
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL?
❑ YES O NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
;THIS.SECTION IS FOR STORAGE TANK IDENTIFICATION
.TANK .07 . '.
vic" ME
UNLF"ED
REGULAR
PREMIUM
DIEM
OTHER
Tank Testing Company
NAME OF TESTING CO \� � --F;;ONE
NUMBER
MAILING ADDRESS
NAME OF TESTER
ICC# e —
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
ICCit
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DAEIIPPROVED• APPROVED BY
FD2086 (Rev 08/09)