HomeMy WebLinkAboutMM Application 6-8-22:BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK Prevention Services
2101 H Street
PERMIT APPLICATION t Bakersfield, CA 93301
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW
Phone: 661-326-3979 • Fax: 661-8S2-2171
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Page ivfi
,Permit #
TYPE OF APPLICATION: NEW TANK INSTALL/NEW FACILITY rNE -TANK INSTALL/EXISTING FACILITY
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STARTING DATE/
PROP _ ED COMPLETION DATE
FACILITY NAME
EXISTING FACILITY PERMIT #
FACILITY ADDRESS C A
ZIP COD�4E
0
TYPE OF BUSINESS r APN #
TANK OWNER PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR
CA LICENSE #
SO
ICC #
ADDRESS
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CITY
SJ;Ple
ZIP
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PHONE # BAKERSFIELD CITY BUSINESS LICENSE # WORKMANS COMP # INSURER
C,
BRIEFLY DESCRIBE THE WORK TO BE DONE.
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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?
YES 171 NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
YES E] NO
THIS SECTION IS FOR STORAGE TANK IDENTIFICATION
TANK #
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL t OTHER
C:D—
vll�
Tank Testing Company
NAME OF TESTING COMPAN PHONE NUMBER
verLou
MAILING ADDRESS ct -
NAME OF TESTER 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 PER3URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER �I'� ICC#
_ ` n
CA a LA
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
DATE APPROVED
i APPROVED BY