HomeMy WebLinkAbout6501 Union minor mod application 4-1-19_4-4UNDERGROUND STORAGE TANK
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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
STARTING DATE/ PROPOSED COMPLETION DATE
FACILITY NAME EXISTING FAaLTTY PERMIT #
mini mafA:
FACILITY ADDRESS t �, n _ ► . _ _ d1 _ CITY /-".I J^ ac-<- _ .., I ZIP,EQEZL
TYPE OF BUSINESSV l Q W^ ( APN # I
OWNERTANK
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BRIEFLY DESCRIBE THE WORKTO BE DONE:
LL
I WATER TO
I DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
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ADDRESSMAILING
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NAME OF i
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 r n ICC#
FOR OFFICIAL USE ONLY
'DATE APPROVED APPROVED'' BY
FD2086 (Rev 08/09)