HomeMy WebLinkAbout2021_10_19 Sams Club_ApplicationAPPLICATION
TO PERFORM ELD/LINE TESTING/
SB989 SECONDARY CONTAINMENT
TESTING/TANK TIGHTNESS TEST AND
FUEL MONITORING CERTIFICATION
(Please note ti -tat these are separate
individual test -s and will be charged per
separate type test accordingly.)
PERMIT #
0 ENHANCED LEAK DETECTION 0 LINE TESTING
11 TANK TIGHTNESS i*UEL MONITORING CERTIFICATION
BIAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661-326-3979 ® Fax: 661-852-2171
Page 1 of I
0 SB -989 SECONDARY CONTAINMENT
11 OVERFILL PREVENTION
FD2095 (Rev 03/18)
SITE INFORMATION
FaLITY
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NAME & PHONE +,' OF CONTACT PERSON
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ADDRESS
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OWNER NAME
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OPERATORNAME
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PERMIT TO OPERATE
# OF TANKS TO BE TESTED:
IS PIPING GOING TO BE TESTED? 0 YES 13 NO
TANK #
VOLUME
CONTENTS
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TANK TESTING COMPANY
TESTING COMPANY
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NAME & PHONE OF CONTACT PERSON
MAILING ADDRESS
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N M �TER OR SPECIAL Al E & PH # OF LINSPECTOR
CERTIFICATION #
TEST METHOD
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ICC #
APPLICANT SIGNATU
DATE
THIS#'AICATION
BECOMES A PERMIT WHEN APPROVED
APPROVED BY
V
DATE
FD2095 (Rev 03/18)