HomeMy WebLinkAboutMINOR MOD APP 12.27.18.1-AKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
Prevention Services
..
O1 Avenue, Floor
15 Truxtun Avenu �
., ._. .. .. ....,.. _ ..,._ _., ...
PERMIT APPLICATI ®N
x $ ?
Bakersfield, CA 93301
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILI'T'Y)/NEW .;:: <iRe
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Phone: 661 -326 -3979 •Fax: 661 - 852 -2171
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Page 1 of 1
;Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY
LL ACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY
INOR MODIFICATION OF FACI
STARTING DATE/
PROPOSED.COM
FACILITY NAME
EXISTING FACILITY PERMIT.#
FACILITY ADDRESS
CITY
r
kka
ZIP
TYPE OF BUSINESS
APN #
TANK OWNER !"
PHONE #
ADDRESS
CITY
ZIP
CONTRACTOR
ADDRESS
CITY
ZI O
PHO . #
BAKERSFi CITY BUSINESS LICENS
WORKMANS COMP #
INSURER
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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?
113 YES ❑ NO D YES ❑ NO
THIS SECTION IS FOR STORAGE "WANK IDENTIFICATION
TANK #. VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER '
ry
Tank Testing Company
NAME OF TESTING COMPAN PHON UMBER
MAILING ADDRESS non CA 1r11%
NAME OF TESTER ICC#
U jRtr V)
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 ICC#
1GUWWD-
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
D.ATE4PPROVED:
APPROVED BY
FD2086 (Rev 08/'09)