HomeMy WebLinkAboutMINOR MOD APP 3.6.19UNDERGROUND STORAGE TANK
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PERMIT APPLICATION
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD - MINOR MOD
;Permit #
T ITY
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FAC
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR ODIFICATION OF ACILITY
STARTING DATE/ PROPOSED COMP TE
EXISTING FACILITY PERMIT #
FACILITY NAME r
ZIP CODE
FACILITY ADDRESS t— . `` ti In n CITY �OtrC��\ �.
TYPE OF BUSINESS � •�= _'�'"'t ����,,
TANK OWNER
ADDRESS
APN #
PHONE #
ZIP CODE
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?
El YES C3 NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED M
REGULAR PREMIUM. .:.DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY ---ONE MBER ®^-�
Q /
MAILING ADDRESS C! ,,.. KJ- - t A C
11 ��.. UUU
NAME OF TESTER _ , \ " i r ICC# l f
THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS
PERMIT AND ANY OTHER STATE, URY AND TO THE BEST OF MY KNOWLEDGE FORM HAS BEEN COMPLETED UNDER
PENALTY OF PER] TRUE AND CORRECT. r
NAME OF TESTER ICC# LCA4o
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)