HomeMy WebLinkAboutUST APPL 7/6/2014UNDERGROUND STORAGE TANKS
PERMIT # ., ct2--j
❑ ENHANCED LEAK DETECTION
❑ TANK TIGHTNESS
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B X S P I D
FIRE
ARM. T
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 -326 -3979 • Fax: 661- 852 -2171
Page 1 of 1
❑ LINE TESTING ❑ SB -989 SECONDARY CONTAINMENT
B FUEL MONITORING CERTIFICATION
SITE INFORMATION
FACILITY
Corner Store 3074
NAME & PHONE # OF CONTACT PERSON
Manager 661- 324 -9481
ADDRESS
3225 Buck Owens Blvd, Bakersfield, CA 93301
OWNER NAME
Corner Store
OPERATOR NAME
Sandy Huff
PERMIT TO OPERATE #
# OF TANKS TO BE TESTED:
IS PIPING GOING TO BE TESTED? ® YES ❑ NO
TANK #
VOLUME
CONTENTS
3 -87
14130
Unleaded Gas
4 -91
10140
Premium
6- Diesel
20068
Diesel
TANK TESTING COMPANY
TESTING COMPANY
Tanknology
NAME & PHONE # OF CONTACT PERSON
Jerry Belloli 209 - 365 -1246
MAILING ADDRESS
1024 Industrial Way Suite A/B, Lodi CA 95240
NAME & PHONE # OF TESTER OR SPECIAL INSPECTOR
Darren Sciume 209- 400 -4589
CERTIFICATION #
ICC Service Technician
DATE & TIME TEST TO BE CONDUCTED
Tuesday June 24th @ 9:00 am
ICC #
5261281 Expires 7/612014
TEST METHOD
T
APPLICANT SIGNATURE
DATE
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APPROVED BY
DATE
bel
c '
FD2095 (Rev 03/08)
UNDERGROUND STORAGE TANK
50.1
PERMIT APPLICATION
TO OPERATE AN UST ..r,
PERMIT # /7 6PW 2-
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661- 326 -3979 • Fax: 661- 852 -2171
TYPE OF APPLICATION (CHECK)
❑ OPERATE NEW FACILITY ❑ TRANSFER OF OWNERSHIP no OPERATE AN EXISTING FACILITY
E
RESS
E#
CODE
APPLICANT'S NAME; (if different from owner)_
NAME PHONE#
Tanknology 209 -365 -1246
ZIP CODE
1024 Industrial Way Suite A/B Lodi 95240
TANK LOCATION
FACILITY NAME OPPERATOR NAME PHONE #
Corner Store 3074 Sandy Huff
ZIP CODE
Fi2"2-5 Buck Owens Blvd Bakersfield 193301
EMERGENCY CONTACT
NAME PHONE #
Jerry Belloli 209- 365 -1246
ADDRESS CITY ZIP CODE
1024 Industrial Way Suite A/B Lodi 95240
TANK INFORMATION
TANK '-# VOLUME DATE INSTALLED SUBSTANCE STORED PREVIOUS SUBSTANCE
3 -87 14130
4 -91 10140
6- Deisel 20068
Do you have a HAZARDOUS
MATERIAL RESPONSE PLAN?
YES
❑
NO
Do you have an OWNER - OPERATOR
AGREEMENT?
MM
YES
❑
NO
Have you filled out a HAZARDOUS
MATERIAL BUSINESS PLAN?
W
YES
❑
NO
FOR OFFICIAL USE ONLY
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 06/10)