HomeMy WebLinkAboutTemp Closure 9-29-2020_4-4UNDERGROUND STORAGE TANK
PERMIT APPL KATION
TO CONSTRU--T-INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INST y -L (EXISTING FACILITY)/MOD-MINOR MOD
Permit #
BAKERSFIELD FIRE DEPARTMENT
0
Prevt� ntion Services - - -
2101 f - Street
Bakersfield, CA 93301
Phone: 661-326-3979 9 Fax: 661-852-2171
Page 1 of 1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(CHECK ONE ONLYj) ❑ MODIFICATION OF FACILITY '4�MINO" MODIFICATION OF FACTLTTY
STARTING DATE/ PROPOSED COMPLETION DATE
FACILITY NAME EXISTING FACILITY PERMIT #
FACILITY ADDRES �
CITY
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ZIP COD
TYPE OF BUSINESS
S ti�
A P N #
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TANK OWNERPHONE
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#
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ADDRESS !
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CITY6ZIP
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ICC
CONTRALTO' -/xe V I- j
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ADDRESS
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ZIP C QE
PHONE �S_u
BAKERSFIELD CITY BUSINE I
WORKMANS COMP #
INSU R
BRIEFLY DESCRIBE THE WORK TO BE DONE:
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WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
1
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO ❑ YES ❑ NO
THIS SFCTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED
REGULAR PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY PHONE NUMBER
MAILING ADDRESS
NAME OF TESTER ICC#
THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ,%TTACHED 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 WHEV APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVE. j
APPROVED BY
f-UZU613 �Kev i i/zu15)