HomeMy WebLinkAboutMINOR MOD APP 8-29-18•
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
7HIS SEC 76 ON IS FOR STORAGE TANK IDENTIFICA71O
TANK #- VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
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Tank TezUng Comp any
NAME OF TESTING COMPANY ONE NUMBER (4�92,
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MAILING ADDRESS
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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#
(I �__
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)
DEPARTMENT
UNDERGROUND STORAGE TANK
`BAKERSFIELDFIRE
Prevention Services
1501 TruXtun Avenue, 1st Floor
PERMIT APPLICATION
g s n
; ' FIRE
Bakersfield, CA 93301
Phone: 661 -326 -3979 • Fax: 661 -852 -2171
TO CONSTRUCT- INSTALL NEW TANK (NEW FA CILITY)/NEW
gRTM r
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Page 1 of 1
;Permit #
TYPE OF APPLICATION!: ❑ NEW TANK INSTALL /NEW FACILITY
TALL /EXISTING FACILITY
CHECK ONCE ONLY ❑ MODIFICATION OF FACILITY
MINOR MODIFICATION OF F
STARTING DATE/
PROPOSED COMPLEX
EXISTING FACILITY PERMIT #
FACILITY NAME
f A-
FACILITY ADDRESS
CITY
ZI
•
TYPE OF BUSINESS
APN #
PHONE #
TANK OWNER
CITY
ZIP CODE
ADDRESS
CONTRACTOR
CA S
I
ADDRESS
CITY
s.
PHONE #1
s v
BAKE L BU I
C SE #
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
7HIS SEC 76 ON IS FOR STORAGE TANK IDENTIFICA71O
TANK #- VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
f'\ t�
V
V !�./
Tank TezUng Comp any
NAME OF TESTING COMPANY ONE NUMBER (4�92,
-fd
MAILING ADDRESS
f
cA
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#
(I �__
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)