HomeMy WebLinkAboutMINOR MOD Application 3-10-22UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Permit #
TYPE OF APPLICATION: F-1 NEW TANK INSTALL/NEW FACILITY
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BAKERSFIELD FIRE DEPARTMENT
Prevention Services
44
2101 H Street
Bakersfield, CA 93301
Phone: 661-326-3979 • Fax: 661-852-2171
Page 1ofI
VEVW TANK INSTALL/EXISTING FACILITY
OR M[)nTFT('ATT[lN ()F FACTLITY
STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAME vcd
CA
EXISTING FACILITY PERMIT #
FACILITY ADDRESS (A t
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TYPE OF BUSINESS d
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AFN #
TANK OWNER
Nil
PHONE # / „ (4�1(4
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ADDRESS ,
CIT ZIP C"
CONTRACTORCA
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LICENSE # ICC #
ADDRESS�`
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CITY ZIP��
PHONE #��/^j. C/^Y'\'
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BAKERSFIELD CITY BUSINESS LICENSE #
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WORKMANS COMP # INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
WATER TO FACILITY PROVIDED BY
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 M YES E] NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # !VOLUME UNLEADED iREGULAR PREMIUM DIESEL iOTHER
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Tank Testing Company
NAME OF TESTING COMPANR PHONE NUMBER
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� MAILING ADDRESS
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NAME OF TESTER ICC# V t L
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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER ICC#
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DATE APPROVED
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
APPROVED BY
FD2086 (Rev 11/2015)