HomeMy WebLinkAbout2317 L ST MOD APP 2015UNDERGROUND STORAGE TANK
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CAyCE aE #
PERMIT APPLICATION
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TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW
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TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
ADDRESS
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ZIP V,_,,
Permit #
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BAKERELD CITY BUSINESS LICENSE #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661- 326 -3979 a Fax: 661- 852 -2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(CHECK ONE ONLY ) U MODIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACILITY
STARTING DATE/ PROPOSED COMPLETION DATE
FACILITY NAME EXISTING FACILITY PERMIT #
FACILITY ADDRESS 9� 1 —1 L CITY ZIP &j-uE le,' A
CODE
TYPE OF BUSINESS La�, �5k— 1 APN #
TANK OWNER PHONE #
1 ADDRESS
CITY
ZIP CODE
CONTRACTOR 1
CAyCE aE #
ICC #
ADDRESS
C _
ZIP V,_,,
PHONE #
BAKERELD CITY BUSINESS LICENSE #
WOS COMP
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE: i B"TO°i'% Z.
if _ n
I WATER TO FACILITY PROVIDED BY
I 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?
❑ YES ❑ NO 1 ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTITFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL - OTHER
Tank Testing Company
NAME OF TESTING COMPANY
MAILING ADDRESS
NAME OF TESTER
PHONE NUMBER
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 PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICC#
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
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