HomeMy WebLinkAboutUST-APPL 2/3/2015UNDERGROUND STORAGE TANKS
APPLICATION
TO PERFORM ELD/LINE TESTING/
SB989 SECONDARY CONTAINMENT
TESTING/TANK TIGHTNESS TEST AND
FUEL MONITORING CERTIFICATION
(Please note that these are separate
individual tests and will be charged per
separate type test accordingly.)
PERMIT #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
3411 S 11 41,7.-D 2101 H Street
Bakersfield, CA 93301
R r Phone: 661-326-3979 • Fax: 661-852-2171
Page I of I
❑ ENHANCED LEAK DETECTION ❑ LINE TESTING ❑ SB-989 SECONDARY CONTAINMENT
❑ TANK TIGHTNESS @"-FUEL MONITORING CERTIFICATION
SITE INFORMATION
FACILITY. ' NAME & PHONE * OF CONTACT PERSON
ADDRESS ZOO
OWNER NAME
OPERATOR NAME— PERMIT TO OPERATE #
+ tbE:L
# OF TANKS TO BE TESTED: IS PIPING GOING TO BE TESTED? ❑ YES NO
TANK # VOLUME CONTENTS
000 <ALLOtQ E S t-= L
b, oo o <jj L b%G S E- L_
DATE & TIME TEST TO BE CONDUCTED <1 ,, rv-x
a– 10 –, 5
APPLICANT SIGNATURE
Icc # 15 a 'i 7 0;t 8 ;1 TEST METHOD
DATE
D
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APPROVED BY I DATE
it
FD2095 (Rev 03/08)
TANK TESTING COMPANY
TESTING COMPANY
Z.
NAME & PHONE # OF CONTACT PERSON
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MAILING ADDRESS
NAME & PHONE # OF TESTER OR SPECIAL INSPECTOR
CERTIFICATION #
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M -_ . 7% =-A 00" f% 'd7 - 7 '1 . 1 9 ft
L/ I . 0 No; — 2 *:r -r �'z
DATE & TIME TEST TO BE CONDUCTED <1 ,, rv-x
a– 10 –, 5
APPLICANT SIGNATURE
Icc # 15 a 'i 7 0;t 8 ;1 TEST METHOD
DATE
D
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APPROVED BY I DATE
it
FD2095 (Rev 03/08)