HomeMy WebLinkAboutSB989 Application 7-23-21UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MSD
Permit #
TYPE OF APPLICATION:
(CHECK ONF ONLY)
BAKERSFIELD FIRE DEPARTMENT
1*41%p
Prevention Services
FACILITY NAME �M
2101 H Street
8R S F, D
_E
�FI
CITY
s
1
Bakersfield, CA 93301
w r
Phone: 661-326-3979 • Fax: 661-852-2171
Page 1of1
❑ NEW TANK INSTALL/NEW FACILITY ❑ NEW TANK INSTALL/EXISTING FACILITY
Fl MnDTFTC'ATTnN OF FAC'TI TTY �MTNOP MnDTFT("'ATTCIN OF FAl'TI TTY
STARTING DATE/
P
PROPOSED COMPLETION DATE
FACILITY NAME �M
EXISTING FACILITY PERMIT #
FACILITY ADDRESS
CITY
ZIP COD
TYPE OF BUSINESS '
LJ ?�kr*/ L <,q.,
APN #
TANK OWNERZ
otj
0-1
PHONE90452Z'7
ADDRESS
CITY �Opp
ZIP CODE
CONTRACTOR DI b4d,
u s�
CA LIC SE
ICC #
A?$ 0AZv+
ADDRESS1�3 I �
CITY
ZIP COD
PHONE # ;107
BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #
a-ST07404a o0
SURER
r
BRIEFLY DESCRIBE THE WORK TO BE DONE;
•
/V
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED i ARE THEY FOR MOTOR FUEL?
❑ YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
U2 FOR FOR STORAGE TANK IDENTIFICATIOV
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
TANK MANUFACTURER
NAME OF TESTING COMPANY � �. � /�� � PHONE NUMBEyutv)
MAILING ADDRESS
NAME OF TESTER _ 14
1AIt5SW
ICC#
eo
THE APPLICANT HAS RECEIVED, UNDE STANDS, 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#
A/�:O Af f_�
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
APPROVED BY
F ULU00 (Kev i 1/LUiS)