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PERMIT APPLICATION`'
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TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW FISH
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD 'Y:
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Permit #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1st Floor
Bakersfield, CA 93301
Phone: 661 -326 -3979 • Fax: 661 -852 -2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/E)ISTING FACILITY
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CHECK ONE ONLY u 1V1UU1r1% -M 11viv yr I .- %%..LL-L I I
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STARTING DATE/ s� PRt3POSED
COMP ON DATE-
1-1 0 A 1 4f
FACILITY NAM EXISTING FACILITY PERMIT #
FACILITY ADDRESS . JCITY ZIP COD
TYPE OF BUSINESS APN #
TANK OWNER
PHONE # Dwo
ADDRESS
C"
ZIP CODE
CONTRALTO -
CA LICENSE #
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ADDRESS
ZIP
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PHONE � � .
BAKE FIELD CITY BUSINESS LICENSE #
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WORKMANS COMP #
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INSURER
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Q\,61
BRIEFLY DESCRIBE THE WORK TO BE DONE: R15 .- •'' ''' v ...� AA 0
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WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL?
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
❑ YES ❑ NO
7 IS,SECTION IS FOR STORAGE TANK IDENTIFICATION
VOWME
UNLF"ED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTING CO
PHONE NUMBER ` ..`�C�a V ��,brl
MAILING ADDRESS����
NAME OF TESTE
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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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
Did�AEAPPROVED.
AP D BY
FD2086 (Rev 08/09)