HomeMy WebLinkAboutMinor Mod Application 3-29-22BAKERSFIELD 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
Page 1 of 1
3
Permit #
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TYPE OF APPLICATION: FINEW TANK INSTALL/NEW FACILITY NEW TANK INSTALL/EXISTING FACILITY
CHECK ONE ONLY [:] MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/ ..� .� PROPOSED
COMPLETION DATE
FACILITY NAME
5 L4
EXISTING FACILITY PERMIT #
FACILITY ADDRESS %
CITY
ZIP COD(J Oj
TYPE OF BUSINESS �
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APN #
TANK OWNER V4
PHONE #
ADDRESS � � � i
CITY /� � �
ZIP COD 7
CONTRACTOR '
CA LICENSE # _^
ICC # 3 6f
ADDRESS
CITY(
ZIP COD)FE j�
PHONE # v
BAKERSFIELD CITY BUSINESS LICENSE #
WORKMANS COMP #�, ` �� 4
INSUR�
BRIEFLY DESCRIBE THE WORK TO BE DONE:
4PI
I IV
VJ5 t z- 4�1 LA 4 -
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?
171 YES NO Q YES Q NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK # VOLUME
UNLEADED REGULAR PREMIUM
DIESEL OTHER
I
Wank Testing Company
NAME OF TESTING COMPANYPHONE
LAI- 2, '"
NUMBER % f �� r�
C V y
MAILING ADDRESS �
619g:51jag:,,, k�4� fi e c� �/4
,6NAME
OF TESTER C.b S / l� 6 V* 3
(n � y �l
ICC# �--
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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 CORRECT.
NAME OF TESTER
ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
FD2086 (Rev 11/2015)