HomeMy WebLinkAboutMINOR MOD Application 3-16-22WATER 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 ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # I VOLUME I UNLEADED I REGULAR I PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY RIC
PHONE NUMBER (ju 031 oe�
MAILING ADDRESS5 -
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NAME OF TESTER ICC#
QN-11
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#
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THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED I APPROVED BY
FD2086 (Rev 08/09)
BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK
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Prevention Services
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1501 Truxtun Avenue, 1st Floor
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PERMIT APPLICATION
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Bakersfield, CA 93301
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW/ll
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Phone: 661-326-3979 Fax: 661-852-2171
TANK INSTALL EXISTING FACILITY)/MOD-MINOR MOD
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Page 1 of 1
- IPermit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW
FACILITY ❑
NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY ❑ MODIFICATION OF FACILITY
MINOR MODIFICA_TI_0N0_F_FA_CTEM
STARTING DATE/
PROPOSED COMPLETIO
FACILITY NAME
EXISTING FACILITY PERMIT #
FACILITY ADDRESS
CITY
ZIP
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TYPE OF BUSINESS /
APN #
TANK OWNER
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PHONE # 139 <�
ADDRESS
CITY
ZIP 61r� ta
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ADDRESS
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ZIP
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PHONE #
BAKE FI INEWORKMANS
COMP #
INSURER
BRIEFLY DESCRIBE THE WORK TO BE DONE: in /--I
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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 ❑ YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # I VOLUME I UNLEADED I REGULAR I PREMIUM DIESEL OTHER
Tank Testing Company
NAME OF TESTING COMPANY RIC
PHONE NUMBER (ju 031 oe�
MAILING ADDRESS5 -
C+
- -�
NAME OF TESTER ICC#
QN-11
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#
L
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED I APPROVED BY
FD2086 (Rev 08/09)