HomeMy WebLinkAboutUST-APPL 3/11/2014APPLICATION
TO PERFORM ELD /LINE TESTING/
SS989 SECONDARY CONTAINMENT TESTING/
TANK TIGHTNESS TEST AND
FUEL MONITORING CERTIFICATION
(Please note that these are separate Individual
tests and will be cfiarged separately per test type
accordingly).
PERMIT NO. I
❑ ENHANCED LEAK DETECTION ❑ LINE TESTING ❑ SB -989 SECONDARY CONTAINMENT TESTING
❑ TANK TIGHTNESS TEST FUEL MONITORING CERTIFICATION
SITE INFORMATION .
FACILITY NAME & PHONE NUMBER OF CONTACT PERSON
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ADDRESS f'
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OWNER NAME
OPERATOR NAME ii CA
PERMIT TO OPERATE #
NO. OF TANKS TO BE TESTED
IS PIPING GOING TO BE TESTED? CJ YES NO
TANK #
VOLUME
CONTENTS
I
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; TESTING CQMP,�1�Y =4_._
NAME OF TESTING COMPANY
NAME & PHONE NUMBER OF CONTACT PERSON
MAILING ADDRESS � C) TZ QS E (A L E
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NAME & PHONE NUMBER OF TESTER OR SPECIAL INSPECTOR
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CERTIFICATION #
DATE & TIME TEST TO BE CONDUCTED
ICC # J
TEST METHOD
SIGNATURE OF APPLICANT DATE
C7 tom- 1 1
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APPROVED BY
DATE
FDZU95 (Rev. 03/08)