HomeMy WebLinkAboutminor mod Application 8-27-21BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
2101 H Street
PERMIT APPLICATION Bakersfield, CA 93301
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW Phone: 661-326-3979 • Fax: 661-852-2171
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
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Permit #
TYPE OF APPLICATION: F-1 NEW TANK INSTALL/NEW FACILITY F-1 NEW TANK INSTALL/EXISTING FACILITY
C'HFC'K nNF CONI Y) F mor)TFTATTO \I nF FA( -TI TTY I I MTI\InF? M()r)TFT('ATT()l\I nP PA( -T1 TTV
STARTING DATE/ 08/23/21 PROPOSED COMPLETION DATE 08/27/21
FACILITY NAME SAM'S CLUB GAS STATION #4819 1EXISTING FACILITY PERMIT #
FACILITY ADDRESS 5625 GOSFORD RD. CITY BAKERSFIELD ZIP CODE 93313
TYPE OF BUSINESS GAS STATION APN #,
TANK OWNER SAM'S CLUB WEST PHONE 479.277.7388
ADDRESS 702 S.W. 8TH ST. CITY BENTONVILLE ZIP CODE 92716
CONTACTOR JAU REG U I & CULVER, INC . CA LICENSE 708231 ICC # 818241
ADDRESS 959 W MISSION AVE CITY ESCO N D I DO ZIP CODE 92025
PHONE =760.743.0518 BAKERSFIELD CITY BUSINESS LICENSE #
22-001144993
WORKMANS COMP # 9040631-21 INSURER STATE FUND
BRIEFLY DESCRIBE THE WORK TO BE DONE:
REPLACE (4) EXISTING STRAIGHT DROP TUBES WITH OPW 71 SO -410C OVERFILL DROP TUBES.
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
OF TANKS TO BE INSTALLED ARE THEY FOR N10TOR FUEL?SPILL
YES MNO
PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
YES NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
T1 207000 NORTH 20K
T2 207000 SOUTH 20K
T3 207000 12K 8K
Tank Testing Company
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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