HomeMy WebLinkAboutMINOR MOD APP 9-6-18PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
BAKE SFIELD FIRE DEPARTMENT
0 Prevention Services
2101 H Street
i Bakersfield, CA 93301
Phone: 661 -326 -3979 ® Fax: 661- 852 -2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
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STARTING DATE / PROPOSED
COMPLETION DATE
FACILITY NAME
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EXISTING FACILITY PERMIT #
FACILITY ADDRES -
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ZIP
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OID
TYPE OF BUSINESS(
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APN #
TANK OWNER
PHONE # 90q 1 + I- � u 14
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ADDRESS
CITY
ZIP CODE
CONTRACTOR r _
LICENSE #�' �
ICG # 5 7.-�_4f-a
ADDRESS
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ZIP CODE
PHON # `���
BAKER iELD�CITY BUSIN LICENSE #
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WORKMANS OMP #
I URER
BRIEFLY DESCRIBE THE WORK TO BE D NE:
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
THE THES SECTION IS POP, STORAGE 7AMK EDEN 7 ZFECA7 -ECu
TANK #-
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
7ank Testing Company
NAME OF TESTING COMP S59 �
PHONE NUMBER,* (= ,.r.,..
MAILING ADDRESS
C-✓ CAL
NAME OF TESTER
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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 E-�""� � ICC# � �a�C9
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
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