HomeMy WebLinkAboutUST APPUNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO OPERATE AN UST
PERMIT #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661-326-3979 a Fax: 661-852-2171
TYPE OF APPLICATION (CHECK)
❑ OPERATE NEW FACILITY ❑ TRANSFER OF OWNERSHIP Ful OPERATE AN EXISTING FACILITY
Do you have a HAZARDOUS MATERIAL RESPONSE PLAN? yhb U 114V
Do you have an OWNER - OPERATOR AGREEMENT? YES ❑ NO
Have you filled out a HAZARDOUS MATERIAL BUSINESS PLAN? ❑ YES ❑ NO
Fn
FOR OFFICIAL USE ONLY
The applicant has received, understands, and will comply with the attached conditions of the 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.
APPLICANT SIGNATURE APPLICANT NAME (PRINT) APPROVED BY
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
S: Forms-Web\Fire\UST\FD2087 UST Permit Application to Operate an UST.doc (Rev 06/10)
PREVIOUS TANK OWNER (It appllCaDle)
. NAME
PHONE #
678-450-2125
Elizabeth Thompson
ADDRESS
1025 Airport Parkway S.W.
CITY
Gainsville, GA
ZIP CODE
30501
NEW TANK OWNER..
HONE #
NAME
7=
ADDRESS
CITY
ZIP CODE
BILLING ADDRESS
CITY
ZIP CODE
TANK OPERATOR if from owner
.,different
PHONE #
NAME
ADDRESS
CITY
ZIP CODE
APPLICANT'S NAME (if different from owner)
PHONE #
NAME
Aaron W. Medina - Tanknology
951-676-4060
ADDRESS
CITY
ZIP CODE
41785 Enterprise Circle South Suite# D Temecula
92590
TANK LOCATION
FACILITY NAME
Carmax# 7281
YOPPE—R—ATOR NAME
Elizabeth Thompson
Elizabeth
PHONE #
661-282-3016__ ....... . . ......
ADDRESS
CITY
ZIP CODE
16801 Colony Street
Bakersfield
93307
EMERGENCY CONTACT
PHONE #
iNAME
678-450-2125
Elizabeth Thompson
ADDRESS
CITY
ZIP CODE
1025 Airport Parkway S.W. Gainsville, GA 30501
TANK INFORMATION
TANK # VOLUME
DATE INSTALLED SUBSTANCE STORED
PREVIOUS SUBSTANCE
12,000
Unkown
87 grade gasoline
N/A
- - --------
i -
Do you have a HAZARDOUS MATERIAL RESPONSE PLAN? yhb U 114V
Do you have an OWNER - OPERATOR AGREEMENT? YES ❑ NO
Have you filled out a HAZARDOUS MATERIAL BUSINESS PLAN? ❑ YES ❑ NO
Fn
FOR OFFICIAL USE ONLY
The applicant has received, understands, and will comply with the attached conditions of the 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.
APPLICANT SIGNATURE APPLICANT NAME (PRINT) APPROVED BY
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
S: Forms-Web\Fire\UST\FD2087 UST Permit Application to Operate an UST.doc (Rev 06/10)