HomeMy WebLinkAboutMINOR MOD APP 12.28.18UNDERGROUND STORAGE TANK
& w�„ '- 16"h, �"' aa�_ 3"'• '+.��3:t�CS.�+k`d:fk.;L::��`.ry ..r.,� ,. .e e:w�'°.u� =J °xs;:s,::a,:
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) ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
BRIEFLY DESCRIBE THE WOV TO BE DONE: M
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 ❑ , NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
Tank Testing Company
NAME OF TESTING COMPANY 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
D2086 (Rev 11/201