HomeMy WebLinkAboutUST-APPL 5/28/2014UNDERGROUND STORAGE TANK Prevention Services
1501 Truxtun Avenue, 1s* Floor
PERMIT APPLICATION B E $ S F I n Bakersfield, CA 93301
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW F /8Ar Phone: 661 - 326 -3979 • Fax: 661- 852 -2171
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TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD 1
Page 1 of 1
;Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
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 ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
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Tank Testing Company
NAME OF TESTING COMPANY r 7 �1 - P ONE NUMBER y „�
MAILING ADDRESS
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NAME OF TESTER r (C_j 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 TEST ICC#
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
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