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11/22/2004 12:47 6613252529
CAL VALLEY
PAGE 01
CITY OF BAKERSFIELD
OFnCEOFE~ONMENTALSERVIC~
1715 Chester A ve.t Bakersfield, CA (661) 326..3979
APPLICATION TO PERFORM
FUEL MONITORING CERTIFICATION
FACIlITY 1?~ (;() m~K~""
ADDRESS ¡(DO VlLhø..lI4. , :
OPERA TORS NAME «~ (;.0 twlW'~it-
OWNBRSNAME S4mL
NAME OF MONITOR MANUFACl'UREUCI'1"O S1-tcr
DOES FACnJTY HA VB DISPENSER PANS? YES--'::::..
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TANK #
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VOLUME
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CONTENTS
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NAME OP'IESTING COMPANY ('.A/-VAllt¡¡ 1E,tc.IIJJt1.fM1-
CONTRAC1'ORS LICENSER 7'LJ/7tJ A. il-Jl2
N~ &: PHONE NUMBER OF CONTACt PERSON ßruu. H7~J1 "J"''12.'7.v'fl
DATE & TIME TEST IS TO BE CONDUC'J'BI) I J- 2..3-"C¡ ti2 Q9!øo
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.APPROVED BY
11-22-fJl.j
DATE
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SIGNATURE OF APPLICANT
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