HomeMy WebLinkAbout2317 L SB_4-4`�-N BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK®�
Prevention Services
FACILITY NAME
2101 H Street
PERMIT APPLICATION
Bakersfield, CA 93301
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW �
Phone: 661-326-3979 P Fax: 661-852-2171
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Page ) of 1
Permit #
CA IUCENSE#
ICC#
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑
NEW TANK INSTALL/EXISTING FACILITY
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MINOR MODIFICATION OF FACILITY
...............__.--- - _ ..___. __.____ _.
STARTING OATS/ ( I PROPOSED
COMPLETION DATE
FACILITY NAME
E%1 HEILIIY REMIT #
FACILItt ADDRESS >
_71 _ L. J 4 ` CITYIF CODE
TYPE OF BUSINESS / AIN x
TANK OWNER
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PHUNEx
ADDRESS
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CITY
ZIP CODE
CONTRACTOR
CA IUCENSE#
ICC#
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ADDRESS po IJIiX {� fJ Per
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PHONE1 // _ IjBAKERGFlELD �CItt BUSINESS LICENSE#
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INSURER A
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BRIEFLY DESCCR" .. THE WORK TO'BE`DONE:
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WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER /
SOIL TYPE EXPECTED AT SUE
A OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR MITI,
0 YES O NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILET
O YES O NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK VOLUME
DNLFJIDED
REGULAR
PREMIUM
DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY
PHONE NUMBER
MAILING ADDRESS/) r'
NANEOFTESTER I/J` 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#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
_
APPROVED BY
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