HomeMy WebLinkAboutMINOR MOD APP_4.30.19UNDERGROUND STORAGE TAN
PERMIT APPLICATION
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILM')/NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Permit #
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FIRE DEPARTMENT
vices
nue, 1st Floor
'301
)79 • Fax: 661-852-2171
OF APPLICATION: ❑ NEW TANK INSTALL/NEW1
BAKERS
Prevention
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�MINOR
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Phone: 661-
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326-
OF FACILITY
Page 1 of 1
IFICATIONNF
FIRE DEPARTMENT
vices
nue, 1st Floor
'301
)79 • Fax: 661-852-2171
OF APPLICATION: ❑ NEW TANK INSTALL/NEW1
FACILIT
�MINOR
5
-TlTYPE
,EXISTING FACILITY
(CHECK ONE ONLY ❑ MODIFICATIO
OF FACILITY
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IFICATIONNF
FACILITY
STARTING DATE/
:PROP6
PLERON
DATE
FACILrrY NAME
EXISTING �
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)ERMIT'#
FACILITY ADDRESS
QTY t7;
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ZIP CODE
'TYPE OF BUSINESS
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APN #
TANK OWNER
PHONE #
ADDRESS
CITY
ZIP CO E
CONTRACT'OR.,I;-�-,
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ICC #
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ADDRESS
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INSURER.
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BRIEFLY DESCRIBE THE WORK TO BE DONE:
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NAME OF TESTER
THE APPLICANT HAS RECEIVED, UNDERSTANDS, AN4 WILL CC MPLY WITH THE ATI HED 'CONDITIONS OF THIS
GUbTI IONS! M 1E
PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL RE THIS FOR BE N COMPLETED UNDER
i
PENALTY OF PERJURY, AND TO THE BEST OF MY CNOWLIEDGE IS TRUE ND C ORRECT.
NAME OF TESTER
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THIS APPLICATION BECO ES A P kMITj PR VED
WHEN A�
�FOR OFFICIAL USE ONLY
APPRO E BY
DAi APPF�OV D D
11 FD2086 (Rev 08/09)