HomeMy WebLinkAboutMOD APP_10-19-18UNDERGROUND STORAGE TANK
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PERMIT APPLICATION
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
IPermit #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
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/EXISTING FACILITY
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STARTING DATE/
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PROPOSED COMPLETION DATE
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FACILITY NAME
XISTING FA&ITY PpwrT #
FACILITY ADDRESS
CITY
ZIP CO2; i5
TYPE OF BUSINESS
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APN #
TANK OWNERE U
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PHONE # -
ADDRESS
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CITY
ZIP CO I �:�
CONTRACTOR I
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ADDRESS C
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ZIP CODEI?
PHONE #
BAKE7qLD CITY BUSINESS LICENSJ#
WORKMANS COMP #
NSURER
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
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
SPILL PREVENTION 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 TESTING COMPANY
PHONE NUMBER
MAILING ADDRESS
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
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ICC*
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
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