HomeMy WebLinkAboutApplication MinorMod 11-5-2020_4-4UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW
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
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TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
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STARTING DATE/ PROPOSED
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COMPLETION DATE
FACILITY NAME
EXISTING FACILITY PERMIT #
FACILITY ADDRESSCITY
ID (Iwow-_
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ZIP D��
OF BUSINESS
APN #
TANK OWNER �^ ^
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PHONE #
ADDRESSCITY
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CONTRA O`,
CA C N #
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CITY
ZIP C�
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PHONE
BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
INS ER
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
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED �-' REGULAR PREMIUM
DIESEL OTHER
Tank Testing Comg)anv
NAME OF TESTING COMPANY
PHONE NUMBER
MAILING ADDRESS
NAME OF TESTER
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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