HomeMy WebLinkAbout3001 SILLECT MOD APP 2015UNDERGROUND STORAGE TANK
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PERMIT APPLICATION KK
TO CONSTRUCT- INSTALL NEW TANK (NEW FACILITY) /NEW
TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(CHECK ONE ONLY QMQDIFICATION OF FACILITY ❑ MINOR MODIFICATION OF FACILITY
STARTING D E/ B �.�- PROPOSED COMPLETION DATE
FACILITY N t ` EXISTING FACILITY PERMIT #
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FACILITY ADPRESS e^e,
TYPE OF MISINESS _
TANK OWNER
ADDRESS ..—, < 1
APN #
PHONE #
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CONTRACT
CA L�J
ICC #'
ADDRESS
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Cr
_Kc
MOE
PHONE '#
BAKERSFIELD C
BUSINESS LICENSE #
WORKMAN MP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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 PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO 1 ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tarok Testing Company
NAME 0"ESPNGp9mp NY PHONE E
MAILINrG ADDRESS
NAME 73 `10 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 OPZERTER ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
Y
FD2086 (Rev 08709)