HomeMy WebLinkAboutpanama 10-11-21_4-5BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK -
Prevention Services
+ -;M,t,. - 1501 Truxtun Avenue, 1 Floor
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Bakersfield, CA 93301
MIT APPLICATION661-326-3979.Fax: 661-852-2171
PER Phone.
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY}/NEW f
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD Page 1 of 1
,Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑ L/EXISTING FACILITY
CHECK ONE ONLY ❑
MODIFICATION OF FACILITY INOR MODI ON OF FACI
STARTING DATE/ PROPOSE
EXISTING FACILITY PERMIT #
FACILITY NAME cz_
CT�FACILITY ADDRESS I r'4 ( �' ZIP i )�
TYPE OF BUSINESS
TANK OWNER �.-In-tna
ADDRESS I
CONTRACTOR
ADDRESS
PHONE #
BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY
APN #
PHONE #
.;
CITY�C T i�6'
ZIP C VF
2 , t J, J
E # _ WORKMANS COMP # INSURER
DEPTH TO GROUND WATER SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLED ARE THEY FOR MOTOR FUEL? SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY ` j l
MAILING ADDRESS �50q`��
NAME OF TESTER I _ ,,. ^ n r•
rock (2�_ —t3kICC'*
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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 COR.RECT.
NAME OF TESTER ICC#
L01 o 4 � U
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 08/09)