HomeMy WebLinkAboutminor app 9-9-18WATER 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
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK 9 VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
1 OL(
X.
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 ?k r-N -- A I Icca - - 11
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
FD2086 (Rev 08/09)
BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
Prevention Services
1501 Truxtun Avenue, l� Floor
PERMIT APPLICATION
E R S F I p
Bakersfield, CA 93301
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NE W
FIRS
.. %, � 'FRIN
A Y14
A YN
R
Phone: 661-326-3979 •Fax: 661 -852-2171
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Page 1 of 1
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
111V__T.AhL1', 11 1111111,&TALL4EXILSTING FACILITY
(CHECK ONE ONLY ❑ MODIFICATION OF FACILITY
_7PROPOSED
I'NOR MO )IFICA N OF FAC
STARTING DATE/
COMPE
FACILITY NAME
EXISTING FACILITY PERMIT #
FACILITY ADDPESS _)yc
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CITY
-TYPE OF BUSINESS
APN #
TANK OWNER
PHONE #
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ADDRESS 00"N
a -A
ZIP CODE
CONTRACTOR
MMS
ICC #
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ADDRESS
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CITY .V_%
ZIP
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RSEI L CITY I J
PHONE # BAKERS D $U IN
L& C
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WORKMANS COMP #
INSURER
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? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK 9 VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
1 OL(
X.
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 ?k r-N -- A I Icca - - 11
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
FD2086 (Rev 08/09)