HomeMy WebLinkAboutMINOR APP 11-19-18PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
1Perrnit # I
•
AKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661- 326 -3979 • Fax: 661 -852 -2171
Page IofI
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY MODIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLETION DATE
FACILITY NAME (',U ', EXISTING FACILITY PERMIT #
FACILITY AD4�DR2150 CI ] ZIP CODE
TYPE OF BUSIN S .. _ 0 JAPN #
TANK OWNER
ADDRESS
CITY
PHONE #
ZIP CODE
CONTRACTOR LICENSE ICC,
ADDRESS , . CITY!, e ZI
PHONE # ;°'" " jt " ""� BA ERSFIELD CITY B�USINE CENSE # WO MANS COMP C SURE
BRIEFLY DESCRIBE THE WORK TO BE DONE::
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
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# OF TANKS TO BE INSTALLED TARE THEY FOR MOTOR FUEL? I SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO ❑ YES ❑ NO
T I'S SECTROM IS FOR. S70RAGE TAM, K IDE 771 7— ICIP147ZOR
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
7ank, Testing Company
NAME OF T gG O, ANY PHONE NUMBER
MAILING ADDRES
NAME 1�E .. -f`�i zcc#
h
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 U ICC# m o
p
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 11/2015)