HomeMy WebLinkAboutMINOR APP 12.27.18"AKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE
TANK
Prevention Services
4r'^a%Y'S'r. u4 Floor
1501 Txtun Avenue,, 1st „.�r.s. _. w..r... ,...r...... _ s F I Bakersfield, CA 93301
PERMIT APPLICATION n^
�.� lr1Ri Phone: 661- 326 -3979 ®Fax: 661- 852 -2171
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW srt AA'Tir T
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Page i of 1
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLETION DATE
EXISTING FACILrTY PERMIT'#
FACILITY NAME
FACILITY ADDRESS i
• APN #
TYPE OF BUSINESS J-P I
PHONE # ��
TANK OWNER _ -�
ZIP CODE
ADDRESS
CONTRALTO
ICC
ADDRESS , C111( Z
PHONE # RSEi ES S WORKMA S:COMR # INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
wV —J
1 •- �►. �.C) (,3 t” .z. — � ~- t c� C�$-c Lam-. Ce &.3* u CTr '"
WATER TO FACILITY PROVIDED BY TriUc�- S�- l�dL��tA �"✓�� ��
piu
S(.-��
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 # YOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
V
Tank Testing Company
NAME OF TESTING COMPANY
MAILING ADDRESS 1 WN 1!� ",'I
NAME OF TESTER 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 ° ICC#
a-41 (a
KA-C
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)