HomeMy WebLinkAboutMINOR MOD APP 7-12-18BAKERSFIELD FIRE DEPARTMENJ
PER
TO CON
TANK I
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'�.���!t . �.��'�J ,���� � , �����,�� �� �,�� F 2101 H Street
IT APPLICATION FIRE Bakersfield, CA 93301
ABTM Phone: 661- 326 -3979 ® Fax: .661- 852 -2171
TRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW , ;�,
STALL (EXISTING FACILITY) /MOD -MINOR MOD
Page 1 of 1
APPLICATIONe ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
ONE ONLY) ❑ MODIFICATION OF FACILITY 9 MINOR MODIFICATION OF FACILITY
Permit
TYPE OF
(CHECK
STARTING
DATE/ f
1
PROPOSED COMPLETION DATE
FACILITY 1AME
EXISTING FACILITY PERMIT #
FACILITY ADDRESS
CITY �r�
ZIP CODE
TYPE OF BUSINESS
X011 � ` �
APN #
TANK OW
ER ,,y ,
PHONE #& /
ADDRESS
,. Jam` �
CITY �s!�
ZIP CQD ®�
CONTRACTOR
j /� � � � o
C.AyLICENSE #
I�CCq/ #q
ADDRESS
f7o >'e ry
G'
CITY 54e$��
ZIP 4
PHONE #
4c
Zz ` .. 5707
BAKERSFIELD CITY BUSINESS LICENSE #
W RKMANS CO.MP�# +y
��►90r, l ZO 4.01-7
INSsURR. ER _
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?
❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
TNES SECTION
IS FOR STORAGE TAN K ZOENTIFECAT ON,
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
TANK MANUFACTURER
U a n 6� 7,ga
.6tong CoMpany
NAME OF
TESTING COMPANY
PHONE NUMBER 7 (jam/ _ "l
MAILING
ADDRESS
NAME OF
TESTER JI
ICC #� ®a,
THE
PERMIT
APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS
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# 5z& 7 9
THIS APPLICATION BECOMES A PERMIT WHEN ,APPROVED
FOR OFFICIAL USE ONLY
DATE APP
OVED
APPROVED BY
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