HomeMy WebLinkAboutMINOR MOD APP 7-10-18WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
1
❑ YES ❑ NO ❑ YES ❑ NO
VIES SEC7ECH IS FOR STORAGE TANK EDEN 7ZF1CA7ZGN
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Tesi2ang Comp anY
NAME OF TESTING COMPANY
ER
MAILING ADDRESS A, c*% ,-RKJ�AA ot�to'�
NAME OF TESTER
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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICCi - I
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
Prevention Services
1S01 Truxtun Avenue,, 1st Floor
•
PERMIT APPLICATION
R S p I p
FIRE
]s aLA
Bakersfield, CA 93301
Phone: 661-326-3979 Fax: 661-852-2171
TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW -:.
R TANF, ly'
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Page 1 of 1
---------- - ------
'Permit # .. . . ......
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑
NEW TANK INSTALL/EXISTING FACILITY
(OH E C K 0 N E-- 0 N LY) MODIFICATION OF FACILITY
5
MODIFICATION OF FA
STARTING DATE/
COMP
PROPOSED comp
•
FACILITY NAME CNn
EXISTING FACILITY PERMIT #
FACILITY ADDRESS
CITY
ZIP CGOE
�5p
TYPE OF BUSINESS
I-no
APN
TANK OWNER
PHONE A
.. a-s —
ADDRESS
CITY
C
ZIP DE
•
CONTRACTOR
YN A rw 0
CA EN
ICC #
bs-'4
ADDRESS
CITY
ZIP
.PHONE # ]-BAKERSFIELD
OL 7),
CITY BUSINESS LICENSE #
MaS
WORKMANS COMP #
INSURER
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? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
1
❑ YES ❑ NO ❑ YES ❑ NO
VIES SEC7ECH IS FOR STORAGE TANK EDEN 7ZF1CA7ZGN
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Tesi2ang Comp anY
NAME OF TESTING COMPANY
ER
MAILING ADDRESS A, c*% ,-RKJ�AA ot�to'�
NAME OF TESTER
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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICCi - I
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY