HomeMy WebLinkAboutMINOR JOB CARD 3.18.19BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
Prevention Services
�n C v S ti �. j y "'.,m... G. « T" aj .
1501 Truxtun Avenue, 1st Floor
PERMIT APPLICATION B
!";i! F Bakersfield, CA 93301
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW ,..Yry Phone: 661 - 326 -3979 o Fax: 661 - 852 -2171
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD r ��'TJM f
^, Page 1 of 1
!Permit # 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY _ ❑ NEW EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR MOD
STARTING DATE/ PROPOSED CQMPL
FACILITY NAME EXISTING FACILITY PERMIT #
FACILITY ADDRESS CITY (iL
Bd
TYPE OF BUSINESS ' APN #
TANK OWNER PHONE #
0. 0 1- 'n I
Pit 16 r-jA
ADDRESS CITY
CONTRACTOR N
_ .. IGC #
ADDRESS
PHONE;, BAK
Rs BSI CENSE.# WORKMANS COMP # INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY v
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED 7110 RE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
YES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # YOIdiME UNLEADED REGULAR ' ` PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPAN E U Q
MAILING ADDRESS
NAME OF TESTER % ^ at ^ A A d . , k E ) - ^ n., I 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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER .-- ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED '
APPROVED BY.
FD2086 (Rev 08/09)