HomeMy WebLinkAboutmod Application 5-12-21UNDERGROUND STORAGE TANK
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
. . . . . . . . . . .
Phone: 661-326-3979 • Fax: 661-852-2171
Page 1 of 1
TYPE OF APPLICATION: 0 NEW TANK INSTALL/NEW FACILITY 0 NEW TANK INSTALL/EXISTING FACILITY
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STARTING DATE/ Ab v PROPOSED
COMPLETION DATE
FACILITY NAME
EXISTING FACILITY PERMIT #
FACILITY ADDRESS
CITY
ZIP CODE
TYPE OF BUSINESS
APN #
TANK OWNER
PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR
Cj 6
CA LIC, NSE#
ICC #
ADDRESSCITY
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PHONE #
7
BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE: k
J
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED
ARE THEY FOR MOTOR FUEL?
0 YES 0 NO 10
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
_ YES ❑0 NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM
DIESEL
OTHER
Tank Testing Company A e,-< 7 e,�41
NAME OF TESTING COMPANY �--PHONE NUMBER
IMP
MAILING ADDRESS
NAME OF TESTER
ICC# Z;ee 9
THE APPLICANT HAS RECEIVED, UNDERSTA`NDSf 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# _-I;p . 4 �61
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
Fn?ORA (Rpv 11/20151