HomeMy WebLinkAboutUST-APPL 3/5/2015UNDERGROUND STORAGE TANK
�., w'r:S°ua.,ttJr �., �.x � ,�''.va.. Y.'.�. ❑E .`..rLi�. sY s..«E�t tip. {$. �kin�:P �, i�.irt : �',�, .'- 'a�.i.�.& �'u�.��'�' kfii :.. �L, ^.FZ",.� .. � h ..�'c.tw..._ �:
PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Permit # �� ,^ �^ 2
yz�
ARfAf r
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661- 326 -3979 ® Fax: 661- 852 -2171
Page Iof1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE / •J,, _ PROPOSED COMPLETION DATE
FACILITY !kL I EXISTING FACILITY PERMIT #
FACILITY ADDRE ZIP CO
TYPE OF BUSINES , APN #
TANK OWNER Q PHONE #
ADDRESS �� CITY <� '"�" —` ZIP CODE
CONTRACTOR CA LICENS # 1 ICC #
ADDRESS S1f CITY _(j ZIP CO 0�
PHONE # ,.-� �� BAKERSFIELD CITY BUS SS LICENSE # WORKMANS CO I SURER
(cUl BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED TARE 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
Tank Testing Company
NAME OF TESTING PHONE NUMB ���
MAILING ADDRESS.
znsf d
1
NAME OF TESTER
J;,C r�� 1 ICC#
_W io
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 TESTER,--^ t � ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
3, .. r.
FD2086 (Rev 08/09;