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UNDERGROUND STORAGE TANK
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PERMIT APPLICATION B a 3 � p
m
TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW ARM
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Permit #
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661- 326 -3979 • Fax: 661- 852 -2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY ❑ NEW TANK INSTALL /EXISTING FACILITY
(("HF('K nNF nNI Y) r-I Mnr)TFTCATTnN nF FACTI TTY M MTNnR MODTFTCATTnN nF FACTLTTY
STARTING DATE/
08/12/2014
PROPOSED COMPLETION DATE
08/12/2014
FACILITY NAME D & G Liquors
I EXISTING FACILITY PERMIT #
FACILITY ADDRESS 2732 Brundage Ln CITY
Bakersfield
ZIP CODE 93304
TYPE OF BUSINESS GDF
APN #
TANK OWNER Jaco Hill
PHONE #
(661) 393 -7000
ADDRESS PG Box 82515
CITY
Bakersfield
Z1
93380 -2515
CONTRACTOR
Confidence UST Services, Inc.
CA LICENSE #
1804904
ICC #
8216722 -UT
ADDRESS CITY
16250 Meacham Road
Bakersfield
ZIP CODE
93314
PHO E #
0661) 631 -3870 1
BAKERSFIELD CITY BUSINESS LICENSE #
32864
WORKMANS COMP #
1308371 -2013
INSURER
State Fund
BRIEFLY DESCRIBE THE WORK TO BE DONE: Replace 3.5 gallon Phil -rite (Fill) Spill Bucket.
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL
TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL? SPILL
❑ YES ❑ NO
PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
1
12000 gal.
X
X
2
12000 gal.
X
X
3
12000 gal.
X
Tank Testing Company
NAME OF TESTING COMPANY
Confidence UST Services, Inc.
PH NE NUMBER
661) 631 -3870
MAILING ADDRESS
16250 Meacham Road, Bakersfield, CA 93314
NAME OF TESTER
Dustin Reese
ICC#
I 8216722 -UT
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
Dustin Reese
ICC#
I 8216722 -UT
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
C'
APPROVED BY
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