HomeMy WebLinkAboutMINOR APP 2.1.19UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW :.
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
;Permit #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
"RINr1501 Truxtun Avenue, 1-t Floor
l Bakersfield, CA 93301
Phone: 661 - 326 -3979 • Fax: 661 - 852 -2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY
❑ NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY MODIFICATION OF FACILITY ❑ MINOR MODIFICATION Or t -AUILL I Y
STARTING DATE/ PROPOSED COMPLETION DATE
FACILITY NAME EXISTING:FACtLTTY PERMIT #
FACILITY ADDRESS ZIP COD -3
TYPE OF BUSINESS APN #
TANK OWNER PHONE
_ n . /t i . C-TTY I---, _ _ —f 1 I ZIP-C-ODE. _ C`
Lv r 2 o its -S Aanri� t nr �cT 2 - �l-
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 # VOLUME UN4EADED REGULAR PREMIUM: DIESEL OTHER
a
Tank Testing Company
NAME OF TESTING COMPANY FkHON UMBER
MAILING ADDRESS (—f ,, CA-
I NAME OF TESTER
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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICC#
. , � W. w—'! � �C'VA �
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
FD2086 (Rev 08/09)