HomeMy WebLinkAboutUST-APPL 4/29/2014UNDERGROUND STORAGE TANKS
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APPLICATION FLRI
TO PERFORM ELD /LINE TESTING/ ry`
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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.)
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
Q10( 1-f 15-ME 'ET
Bakerstield, CA 93:
Phone: 661 - 326 -39'
Page 1 of 1
• Fax: 661 - 852 -2171
HERMIT #
❑ ENHANCED LEAK DETECTION LINE TESTING ❑ SB -989 SECONDARY
❑ TANK TIGHTNESS FUEL MONITORING CERTIFICATION
CONTAINMENT
INFORMATION
FACILITY ® NAP9E & PHONE # OF CONTACT PERSOl
S
ADDRESS
LQ C±
OWNER NAME
lmaj�al_
OPERATOR NAME
PERMIT TO OPERATE #
# OF TANKS TO BE TESTED:
IS PIPING GOING TO BE TESTED? ❑ YES
❑ NO
TANK #
VOLUME
CONTENTS
i
TANK TESTING COMPANY
TESTING COMPANY
NAME & PHONE # OF CONTACT PERSON
�--�
MAILING ADDRESS
5(-Q LA C.:v ERSF k IF-L-b , C A °t 1S -3
NAME & PHONE ,# OF T OR SPECIAL INSPECTOR
CERTIFICATION # C,?0 t 6C
DATE & TIME TEST `rO BE CO DU fED 1 o
APPLICANT SIGNAT E o
ICc #
DATE
410,9
TEST METHOD
HIS APPLICATION BECOMES A PERMIT WHEN APPROVED
APPROVE BY
DATE
FD2095 (Rev 03/08)