HomeMy WebLinkAboutMINOR MOD APP 1.25.19BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
✓ a Prevention Services
sc f, 2101 H Street
CA 93301.
PERMIT APPLICATION �.. Bakersfield,
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW 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 ❑ NEW TANK INSTALL /EXISTING FACILITY
ADDRESS
MODIFICATION OF FACILITY
❑ MINOR MODIFICATION OF FACILITY
STARTING DATE/
ZIP CODE
CONTRACTOR
PROPOSED COMPLETION DATE
FACILITY NAME
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ICC #
EXISTING FACILITY PERMIT#
FACILITY ADDRESS
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1 ZIP CODE
TYPE OF BUSINESS
LPL
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WORKMANS COMP #
APN #
TANK OWNER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
' 7
PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR
j-"�
CE
4
ICC #
ADDRESS
QI- ze.
CITY
ZIP��
PHONE # /
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BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
' 7
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?
❑ YES Ne NO YES ❑ NO
TANK a" VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
NAME OF TESTING COMPANY-/`�9��. NUMBER
MAILING ADDRESS
NAME OF TESTER ICC# J
THE APPLICANT HAS RECEIVED, UNDERSTANDS, A 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
DATE APPROVED I APPROVED BY
1
11/20151