HomeMy WebLinkAboutMINOR MOD APP 8-30-18WATER FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED FRE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
ES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Company If
NAME OF TESTING COMPANY
MBER
�'7
MAILING ADDRESS
NAME OF TESTER ICC# 69
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 PER7URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER '�- 46-- ICC# ® f
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
F02086 (Rev 08/09)
BAKERSFIELD FIRE DEPARTMENT
STORAGE TANK
Preventi ®n Services
UNDERGROUND
1501 Truxtun Avenue, 1 Floor
PERMIT APPLICATION
� �,.� g S F I " � D
` . FINN
Bakersfield, CA 93301
Phone: 661- 326 -3979 • Fax: 661- 852 -2171
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
ARf��
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
page 1 of 1
:Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW
FACILITY
EN W TANK f�ST/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY
INOR MODIFICATION ILITY
STARTING DATE/
PROPOSED COMP
ATE
EXISTING FACILITY PERMIT #
FACILITY NAME
FACILITY ADDRESS r
CITY
Z
APN #
TYPE OF BUSINESS '
TANK OWNER ,
PHONE #
s
CITY,
ZIP
ADDRESS
CA S
IC #
CONTRACTOR
Z
ADDRESS t(
A 0v
PHONE �
r
BAKERSFIE CITY I SS LICE E
�►
WORKMANS COMP #
INSURER
_
BRIEFLY DESCRIBE THE WORK TO BE DONE:
%416
w '
17 1 A
WATER FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED FRE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
ES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Company If
NAME OF TESTING COMPANY
MBER
�'7
MAILING ADDRESS
NAME OF TESTER ICC# 69
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 PER7URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER '�- 46-- ICC# ® f
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
F02086 (Rev 08/09)