HomeMy WebLinkAboutMM Application 6-13-22BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
2161 H Street
PERMIT APPLICATION 4. Bakersfield, CA 93361
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW Phone: 661-326-3979 o Fax: 661-852-2171
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Page 1 of Z
:Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITYjEil.O�EW TANK INSTALL/EXISTING FACILITY
(CHECK ONE ONLY ❑ MODIFICATION OF FACILITY MINOR MODIFICATION OF FACILITY
STARTING DATE/
PROPOSED COMPLETION DATE
FACILITY NAME Chevron
EXISTING FACILITY PERMIT #
FACILITY ADDRESS 9700 Rosedale Hwy.
CITY Bakersfield
ZIP CODE 93312
TYPE OF BUSINESS Fuel Facility
APN #
TANK OWNER
PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR B s s R, Inc.
CA LICENSE #
ICC #5257282
ADDRES58830 Rosedale Hwy. #13
CITY Bakersfield
ZIP CODE 93368
PHONE ; 588-2777
2AKKEER SFIIEL�D2CITY BUSINESS LICENSE #
WORKMANS COMP # 0+996350 /�
INSURER AceArnerlcan
BRIEFLY DESCRIBE THE WORK TO BE DONE:
Replace (91) shear valve in dispenser #11/12 per violation
WATER TO FACILITY PROVIDED BY
DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
# OF TANKS TO BE INSTALLEDARE THEY FOR MOTOR FUEL?
YES NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
YES ❑ NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR PREMIUM 'DIESEL i OTHER
yank Testing Company
NAME OF TESTING COMPANY BSSR, Inc.
PHONE NUMBER 588-2777
MAILING ADDRESS
NAME OF TESTER Fidel Carrillo ICC# 5257282
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
Fidel Carrillo
ICC#
5257282
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED APPROVED BY
i
FD2086 (Rev 01/2022)