HomeMy WebLinkAboutSB989 APP 4.24.19UNDERGROUND STORAGE TANKS
APPLICATION
TO PERFORM ELD /LINE TESTING/
SB989 SECONDARY CONTAINMENT
TESTING /TANK TIGHTNESS TEST AND
FUEL MONITORING CERTIFICATION
(please note that these are separate
individual tests and will be charged per
separate type test accordingly.)
PERMIT # ...,_..
...............
❑ ENHANCED LEAK DETECTION
❑ TANK TIGHTNESS
FACILITY `\ ,
ADDRESS
OWNER NAME n
OPERATOR OPERATOR NAME /E
# OF TANKS TO BE TESTED:
TANK #
C�
TESTING COMPANY
MAILING ADDRESS C -xo�
AKERSFIE :ervi FI E DEPARTMENT
,revention c s
101 H Street
akersfield, CA, 9330
hone: 661-326- 979 Fax: 661- 852 -2171
Sae 1 of 1
❑ LINE T STING SB -989 SEC DARY ; ONTAINMENT
❑ FUEL MONITORING CERTIFICNIFION OVER
STTE iNEO#tMATTON�
NAME & OWE NEj# Or CONTACT PERSOIN
PERMIT TO PERATE
I
IS PIPI G GOING T BE TESL ?
VOLUME
NAME & PHONE # OF TESTER OR SPECIAL INSPECTOR CERTIFIC TIOI!
TEST METHOD ICC #
APPLICANT SIGNAT DATE
# OF CONT
THIS APPLICATION ECO'MES A PER IT WHEN APPR ED
APPROVED BY DATE
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FD2095 (Rev 03/18)