HomeMy WebLinkAboutMINOR MOD APP 8.15.18.,.
BAKERSFIELD FIRE DEPARTMENT
FACILITY NAMEvk' fX ��� �n
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Prevention Services
FACILITY ADDRESS ,
2101 H Street
4
Bakersfield, CA 93301
APN #
Phone: 661 -326 -3979 • Fax: 661 -852 -2171
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TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
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STARTING DATE / p
PROPOSED COMPL ION DATE
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T ISTING FACILITY PERMIT #
FACILITY ADDRESS ,
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ZIP CODE
TYPE OF BUSINESS
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APN #
TANK OWNEk'.
PHONE #
ADDRESS A �e
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ZIP CODE 9
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�` BUSINESS LICENSE #
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INSUREI��
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL
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TYPE EXPECTED AT SITE �l
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# OF TANKS TO BE INSTi.LLED
ARE THEY FOR MOTOR FUEL? SPILL
o YES 0 NO
PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
YES O NO
THIS SL,.TION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
Tank Testing Company
NAME OF TESTIN COMPANY �✓ n
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PHONE NUMBER
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MAILING ADDRESS
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NAME OF TESTER f %ham
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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 F TEST R .
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED _
APPROVED BY