HomeMy WebLinkAboutUST-PERMIT APPL 1/15/2001
I,
¡
r
~
. .it No. þI.. 0 l q ~
. CITY OF BAIffiRS LD -p J. ~ áL d ~l.¡/1 ?
OFFICE OF ENVIRONMENTAL SERVICES
1715 Chester A ve., B~kersfield, CA (805) 326-3979
9te ~OO, q3-3-o
PERMIT APPLICATION TO CONSTRUCTIMODIFY UNDERGROUND STORAGE TANK
~ OF APPLICATION (CHECK)
rv1liŒW FACILITY []MODIFICATION OF FACILITY []NEW TANK INSTALLATION AT EXISTING FACILITY
PROPOSED COMPLETION DATE 1/1 ~ / t') I
EXISTINGfACILIp',P~NO, 'N/A
CITY ~)::.U"s~ ZIP CODE
PHONE ~~) ~IIJ -?4-eJ'30 '
. ZIP CODE t:f ~ I
CA UCENSE NO. 7 ('71 ï'b
ADDRESS ,CITY . ZIP CODE '\o~
PHONE NO. 0 ~ B' C~B SINÇ:SS UCENSE NO.
WORKMAN OMP NO. 0D0+5/- 00 INSURER 9tIi\ Fv~
BRJEFLYDESCRIBE1HEWORKTOBEDONE Ct7^JS~r- ~ ~/'t1L Pllet..
PI{c,JlA'f1? / WI-n-/ I<.It)sk MJO O/JrAJo~.
WATER TO FACILlTY PROVIDED BY c.lTY) vnuT'?
DEP1H TO GROUND WATER ~s SOn.. TYPE EXPEC1ED AT SITE
NO, OF TANKS TO BE INSTALLED 'J- ARE TIIEY FOR MOTOR FUEL "~ YES NO
SPllL PREVENTION CONTROL AND COUNTER MEASURES PLAN ON Fll..E ,....-. YES NO
~,
.
f·
!
I
I
FOR OFFICIAL USE ONLY
1HE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WIDI TIIE ÀTIACHED CONDmONS OF
THIS PERMIT AND ANY 01HER STATE, LOCAL AND FEDERAL REGULATIONS.
THIzFO HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO 1HE BEST OF MY KNOWLEDGE. IS
TRUE . C~FJJEYJ ~ .
i' (Ø~./ Fvp\~1c:. r€hVl;J1F~~
- APPROVED BY: APPUCANf NAME (pRINT) APPUCANf SiaN~TURE 0-'
\
"
..
.'
TANK NO.
t
'2-
VOLUME
1 'J.IC.
tSfc.
.'
~!
~:
TANK NO,
VOLUME
.'
?
"'
SECTION FOR MOTOR FUEL
UNLEADED
v--
REGULAR
PREMIUM
v-
DIESEL
AVIATION
SECTION FOR NON MOTOR FUEL STORAGE TANKS
CHEMICAL STORED
(NO BRAND NAME)
CAS NO. CHEMICAL PREVIOUSLY STORED
(IF KNOWN)
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED