HomeMy WebLinkAboutMINOR MOD APP 6-14-18L11 0 4ZICIZ141110 I RX-3 to] WIT-cl =0 r-MI-111
PERMIT APPLICATION
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXITING FACILTP )/MOD-MINOR MOD
lPermit 2, lawwl
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
8 &E R S F . I D 2101 H Street
FIRE Bakersfield, CA 93301
'I ARrm r Phone: 661-326-3979 9 Fax: 661-852-2171
Page I of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY .0--MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED-COMPLETION DATE'_
FACILITY NAME
i' EXISTING FACILITY'PER
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POK
FACILITY ADDRESS
A �0 / � CITY ZIP
TYPE OF BUSINESS
APN #
TANK OWNER
PHONE #
<1A
ADDRESS
CIT
CITY -eKA k/
zip CO
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CONTRACTOR
CAlldNSE
ADDRESS
CITY
ZIP. 'C
PHONE
BAKERSFI ELD CITY.BUSi.NESS'LIC.ENSEL
WORKMANS COMP
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
MAILING ADDRESS //
NAME OF TESTER ICC# * ___
4: I l
>
Vq I
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 I Icc#
FOR OFFICIAL USE ONLY
DATE APPROVED. APPROVED BY.'
FD2086 C Rev 11/2015)