HomeMy WebLinkAboutMINOR MOD APP 2.8.19BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK _--hot Prevention Services
1501 Truxtun Avenue, 1st Floor
,PERMIT APPLICATION R 9 g D Bakersfield, CA 93301
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! /B'� Phone: 661 - 326 -3979 • Fax: 661 - 852 -2171
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW ABTA T
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD;`
-'` Page 1 of 1
;Permit # wK
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INS AL EXISTING FACILITY
CHECK ONE ONLY2 ❑
MODIFICATION OF FACILITY
MINOR MODIFICATION OF FA ILITY
STARTING DATE /
- PROPOSED CO,MPLE'RON.DA
FACILITY NAME
EXISTING FACiL1TY PERMIT #
FACILITY ADDRESS
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CITY � + �
-N�
P CODE
TYPE OF BUSINESS ('\
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#?
AP
TANK OWNER
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PHONE #
C
ADDRESS
3-LAA
CITY, `
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CONTRACTOR
CA LI CEVS
C#
ADDRESS
Phi ONE
BAK BUSI S
WORKMANS'COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE: I
0
WATER TO FACILnY PROVIDEDI$Y V
FCV"I-> LW_Ak-StjsJ& /,OP4;-;N 5
br%1w- Pert-
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE WAM 0,0V W4
# OF TANKS TO BE INSTALLED I 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 UNLEADED REGULAR PREMIUM D ELI OTHER .
Tank Testing Company/
NAME OF TESTING COMPANY L t� H U ER O�
MAILING ADDRESS
NAME OF TESTER a ICC# P
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 PER7URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER rh r� ' Y tY �1 1 Q1,C1 �/ ICG# IOU 4
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)