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HomeMy WebLinkAboutTank top remodel - Approved permitTYPE OF APPLICATION:  NEW TANK INSTALL/NEW FACILITY  (CHECK ONE ONLY)  MODIFICATION OF FACILITY  STARTING DATE/ PROPOSED COMPLETION DATE FACILITY NAME EXISTING FACILITY PERMIT # FACILITY ADDRESS CITY ZIP CODE TYPE OF BUSINESS APN # TANK OWNER PHONE # ADDRESS CITY ZIP CODE CONTRACTOR CA LICENSE # ICC # ADDRESS CITY ZIP CODE PHONE # BAKERSFIELD CITY BUSINESS LICENSE # 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?  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 OTHER Tank Testing Company NAME OF TESTING COMPANY PHONE NUMBER MAILING ADDRESS NAME OF TESTER ICC# 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 01/2022) PERMIT APPLICATION TO CONSTRUCT-INSTALL NEW TANK (NEW FACILITY)/NEW TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD UNDERGROUND STORAGE TANK Permit # BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661-326-3979 ● Fax: 661-852-2171 Page 1 of 2 NEW TANK INSTALL/EXISTING FACILITY MINOR MODIFICATION OF FACILITY Bakersfield 93311 (661) 631-5880 177 Aviation Street, Shafter, CA. 93311 93308 7608 Fruitvale Avenue (661) 327-9341 23-10000909 01/18/24 23-10000909 01/18/24 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER: COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANYPROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY) POLICY EXP(MM/DD/YYYY) POLICY EFF POLICY NUMBER TYPE OF INSURANCE LTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY 8/14/2023 Armstrong&Associates Insurance Services 239W. Court St. BldgA Woodland CA 95695 Kim Coleman Berger 530-668-2777 530-668-2779 kimcoleberg@armstrongprofessional.com License#: 0B50501 Cypress Insurance Company 10855 CALVALL-03 Cal Valley Equipment, LLC 7608 Fruitvale Avenue Bakersfield CA 93380 1735950078 A X Y CAWC354662 10/21/2022 10/21/2023 1,000,000 1,000,000 1,000,000 When required by Written Contract Waiver of Subrogation applies to Workers' Compensation per the attached endorsement. Re: All Contracts/Written Agreements between the Certificate Holder and the Insured. Brookside at the Oaks 8803 Camino Media Bakersfield, CA 93311 23-10000909 01/18/24 JERRY RANGEL California UST System Operator (Designated) Given this day August 17, 2023 Certificate No. 8900824 23-10000909 01/18/24 JERRY RANGEL California UST Service Technician Given this day August 17, 2023 Certificate No. 8900824 23-10000909 01/18/24 23-10000909 01/18/24 23-10000909 01/18/24