HomeMy WebLinkAboutminor mod Application 1-21-21UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW
TANK I(VSTALL (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
Page 1 of 1
PE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW
TANK INSTALL/EXISTING FACILITY
tCHECK ONE ONLY} ❑ MODIFICATION OF FACILITY
STARTING DATE/ Ao
MINOR MODIFICATION OF FACILITY
t 1 3 L) PROPOSED COMPLETION DATE
FACILITY NAME
C4 A00\ EXISTING FACILITY PERMIT
FACILITY ADDRESS L //.,'
/ G V , � ✓s CITY ZIP
TYPE OF BUSINESS
l �'
�i A P N #
TANK OWNER
�rL y 4 PHONE #
ADDRESS J
CONTRACTOR
ADDRESS
. f
PHONE --#-.BAKERS
FIELD
HONE-- -.BAKERSFIELD
1
BRIEFLY DESCRIBE THE WORK 1-0 BE DONE:
Ak
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WA
CITY
0.1
.CENSE # WORKMH iS CO _
�.e-__ a, 14� �c
ZIP CODE
++tea ICC
ZiP O E:
l,
150 �.0 'it-,
'SOIL TYPE EXPECTED AT SITE
OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL?
SPILL POUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO ❑ YES
❑
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION NO
VOLUME
UNLEADED REGULAR PREMIUM DIESEL
y . OTHER
Tank Testing Companyfi
NAME OF TESTING COMPANY 4
PHONE NUMBER
MAILING ADDRESS
NAM �
E 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
PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT UNDER
NAME OF TESTER '
ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
APPROVED APPROVED BY
FD2086 (Rev 11/2015)