HomeMy WebLinkAboutMINOR MOD APP 11-7-18UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
[Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY
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❑ NEW TANK INSTALL /EXISTING FACILITY
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STARTING DA E/
PROPOSED COMPLETION DATE'
FACILITY NAME
EXISTING? FACILITY PERMIT #
FACILITY ADDRESS ��r
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CITY :5- - 160
ZIP CO'
TYPE OF BUSINESS
✓ ✓ /
APN
TANK OWNER
PHONE #
ADDRESS , 6 r
CITY ) f d� 1
ZIP COQ? F
CONTRACTOR V t't V....
CA LICENSE, #1
ICC #
ADDRESS
CITY', ` %� W
ZIP CODE --�
PHONE #
BAKERSFIELD B, INESS LICENSE #
WORKMA'� ,MP
INSUR b
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
ARE THEY FOR MOTOR FUEL?
p YES ❑ NO
SPILL PREVENTION CONTROL AN; COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATIO
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTING COMPANY � /� ��. �
PHONE NUMBER
MAILING ADi3RES c
NAME OF TESTER
1"
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 LAY KNOWLEDGE IS T??UE AND CORRECT.
NAME OF TESTER
ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY