HomeMy WebLinkAboutApplication MINOR MOD 3-15-21UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Permit #
BAKERSFIELD FIRE DEPARTMENT
.a
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661-326-3979 • Fax: 661-852-2171
Page 1of1
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
(CHECK ONE ONLY) (-1 MC)DTFTC'ATTnN nF FArTI TTY F- MTNnP mnr)TFTC'ATTnN nF FAMI TTY
STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAME _ 4-D
EXISTING FACILITY PERMIT #
FACILITY ADDRESSQ� ��>,J^
CITY �/e
ZIP CODE D
TYPE OF BUSINESS
/
Q A _e: - —
APN #
TANK OWNER �..,
A -7 -7 -
PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR 0�1/ CA LICENSE #
ADDRESS CITY
ICC #
ZIP CODE
PHONE # / �l�
Sul �
BAKERSFIELD CITY BUSINESS LICENSE # WORKMANS COMP #
INSUR
BRIEFLY DESCRIBE THE WORK TO BE DONE:
kl'i
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
Q
ARE THEY FOR MOTOR FUEL? SPI
PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? [IYES NO YES ❑ NO
THIS SELI1+UN IS FOR STORAGE TAN IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM DIESEL OTHER
i
prank Testing Cnrnpanv
NAME OF TESTING COMPANY � �
PHONE NUMBER
MAILING ADDRESS
NAME OF TESTER ICC# r
THE APPLICANT HAS RECEIVED, UNDERSTANDS, aD 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
rULUOU (Kev 11/LU15)