HomeMy WebLinkAboutUST APPLUNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO OPERATE AN UST
PERMIT #
TYPE OF APPLICATION (CHECK)
❑ OPERATE NEW FACILITY ❑ TRANSFER OF OWNERSHIP
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 - 326 -3979 e Fax: 661- 852 -2171
M OPERATE AN EXISTING FACILITY
PREVIOUS TANK OWNER (if applicable)
.NAME
Penske
HONE #
610- 603 -8450
ADDRESS
PO Box# 7635
It F I i. D
P CODE
r19603
Flits
NAME
PHONE #
❑ OPERATE NEW FACILITY ❑ TRANSFER OF OWNERSHIP
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 - 326 -3979 e Fax: 661- 852 -2171
M OPERATE AN EXISTING FACILITY
PREVIOUS TANK OWNER (if applicable)
.NAME
Penske
HONE #
610- 603 -8450
ADDRESS
PO Box# 7635
lCITY
1 Reading
P CODE
r19603
NEW TANK OWNER
NAME
PHONE #
ADDRESS
CrTy
ZIP CODE
BILLING ADDRESS
Crry
ZIP CODE
TANK OPERATOR if different from owner)
NAME
HONE#
DRESS CrTy
P CODE
APPLICANT'S NAME (if different from owner)
ME ONE #
DRESS
CITY
P CODE
TANK LOCATION
ACILITY NAME
Penske# CA -094
PPERATOR NAME
Brian Yazemboski
PHONE #
601- 603 -8450
ADDRESS CITY
2929 E. Brundage Bakersfield
ZIP CODE
93307
EMERGENCY CONTACT
NAME
Brian Yazemboski
PHONE #
601 -603 -8450
ADDRESS
PO Box## 7635
CITY P CODE
Reading 19603
TANK INFORMATION
TANK #
VOLUME
DATE INSTALLED
SUBS'T'ANCE STORED
PREVIOUS SUBSTANCE
1
11,594 gallons
unknown
Diesel Fuel
N/A
2
11,594 gallons
unknown
Diesel Fuel
N/A
Do you have a HAZARDOUS MATERIAL RESPONSE PLAN? YES 0 NO
Do you have an OWNER-- OPERATOR AGREEMENT? ® YES O NO
Have you filled out a HAZARDOUS MATERI L U INESS PL N? IC YES ® NO
FOR OFFICIAL USE ONLY t=
The applicant has received, understands, and will comply with the attached conditions of the 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.
APPLICANT SIGNATURE APPLICANT NAME (PRINT) APPROVED BY
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
S: Forms- Web\Fire \UST\FD2087 UST Permit Application to Operate an UST.doc (Rev 06120)