HomeMy WebLinkAboutMAJOR MOD APP 12.13.18UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY
❑ NEW TANK INSTALL /EXISTING FACILITY
(CHECK ONE ONLY) ELI MU U11-IUA i 1U 1\1 Ur rHl.1Li i Y u 1"I11VUK I"IVUlf'll.H I lU1V Ur rHl.1 L1
BRIEFLY DESCRIBE THE WORK TO BE DONE:
Repair Tank Annular Sensor Risers
WATER TO FACILITY PROVIDED BY City Water
DEPTH TO GROUND WATER 276.84 Feet SOIL TYPE EXPECTED AT SITE Dirt and Gravel
# OF TANKS TO BE INSTALLED o ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO N YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
Tank Testing Company
NAME OF TESTING COMPANY N/A PHONE NUMBER
MAILING ADDRESS
NAME OF TESTER I 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 I ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
FD2086 (Rev 1112015)