HomeMy WebLinkAboutMAJOR MOD APP 2018UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Permit # 7
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
0 Phone: 661 - 326 -3979 • Fax: 661- 852 -2171
Page 1of1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
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STARTING DATE/ ' PROPOSED
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COMPLETION DATE
FACILITY NAME i"� p/ /]
EXISTING FACILITY PERMIT #
FACILITY ADDRESS .,.� f,d�j
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ZIP �� 1
TYPE OF BUSINESS
APN #
TANK OWNER
PHONE #
ADDRESS
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CIT '
L%�M
ZIP CODE l
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CONTRACTOR -�' /� 1
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CA LICENSE #
ICC #
ADDRESS
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ZIP CODE �^
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PHONE #6Z/ /J- ----y�
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BAKERS ELD r i YESINESS LICENSE #
WO MA. TP #
INS R R
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BRIEFLY D�E'SCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER "^-- -� 1` SOIL
TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
tL VENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF T STING CO,MPAN' Y - �`
PHONE NUMBER
MAILING ADDRES 6
NAME OF TESTER
ICC#
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
ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
Fnqns;a (Rc v 11/2015)