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HomeMy WebLinkAboutust_7-13UNDERGROUND STORAGE TANK ;. PERMIT APPLICATION FOR REMOVAL / INSTALLATION OF AN UST Permit No: fp D3 0 DAKERSFIELD FIRE DEPT. ✓ Prevention Services a E s S P 2 900 T uxtun Ave., Ste. 210 FIRE Bakersfield, CA 93301 PARTH T Tel: (661) 326 -3979 Fax: (661) 852 -2171 i Paqe 1 of 1 - SITE INFORMATION:. SITE --: • �,p> DORE � �•���� ZIP CODE FACILITY AM - CROSS STREET TANKOWNER/OPERAT R t PHONE NO. 9 (( �'7(s J APN MAILING ADDRFS g 6 CITY ZI C D - CONTRACTOR .INFORMATION.: , COMPANY �e� A9 IDdV t Q PHONE N0. . -1 LICENSE NO. ADDRESS CI T TY [� 7 ZIP CODE INSURANCECARRIER PRELIMINARY ASSESSMENT WORKMENS COMP NO. INFORMATION COMPANY PHONE NO, LICENSE NO. ADDRESS CITY ZIP CODE INSURANCECARRIER WORKMENS COMP NO. TAN K CLEANING IWORMATION - ;- COMPANY GS) S,r- PHONE NO. Gt LICENSE NO. . ADDRESS CITY CODS INSURANCECARRIER WORKMENS COMP No. 001 (4 9 _ 2CZQp WASTE TRANSPORTER IDENTIFICATION NUMBER I RACILITY IDENTIFICATION NUMBER NAME OF RINSATE DISPOSAL FACILITY G C a( w4 Cobb ($1 7 (o aaan ADDRESS CITY TANK TRANSPORTER INFORMATION ZIP CODE COMPANY / PHONE NO. a--� -� ©� LICENSE NO. ---------- - -1 - -- - - - - -- - - - - -_ ..-- - - - - -- ------------- - - - - -- ADDRESS�� l5 a CITY - -- - - -- ----- ._ -___ _.-- _ -- - -- Z1P�ODE------- - -.__. TANK DESTINATION TANK INFOR ATIOiV TANK NO. AGE CHEMICAL DATES CHEMICAL VOLUME STORED STORED PREVIOUSLY STORED L3 r, ifi- E2- Oea 2 -r-0(o �-...► For Official Use Only .APPLICATION-DATE . FACILITY'No, .: .No. OF TANKS : :. = =C T14EAPPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THEATTACHED CONDITIONS OF THIS PERMITAND 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, APPLICANT NAME (PRINT) APPLiC RE APP r €D Y r THIS APPLICATIOeWILL BECOME A PERMIT WHEN APPROVED FD 2062 (Rev. 02105)