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HomeMy WebLinkAbout5643 BROOKS COURT i~ UNDERGROUND STORAGETANKS UNIFI'ED PROGRAM CONSOLIDATED FORMS " ~ ~.,,r-~+'~^~-~'.._..~:~:~~°~,~,:.':"~"'"'.~ r.~ ;.-.~"~" ~',~.~~+~'~;~~ ' APPLICATION (Continued) ~~ OPERATING PERMIT APPLICATION ~~ FACILITY FORM - (STATE FORM A) One form per facJlJty B R S P I F/R~ DL~ARTM • T BAKERSFIELD FIRE DEPT. Prevention Services 900 Truxtun Ave , Suite 210 Bakersfield, CA 93301 Tel.: (661) 326-3979 Fax: (661) 852-2171 Page 2 of 2 . ;. . : . .. ;;. .; ;,, , ., VIII ,PRIMARY , . . ~ DESIGNATED'OPERATOR`INFORMATION,, :, , .,;,. , `.: ,, ..._.„,,,;. RIMARY DESIGNATED OPERATOR NAME t ` ` . D01a , HONE i'~ ~ OI bi- D01b ..`~~0~ USINESS NAME C ~,~ ~ -~ . ~ D01c ILING OR STREET ADDRESS s ~ 3 t ~r ~, DOtd ITY 1 I~ a D001e STAT~~ D01f ~PCODE 001g CC CERT. # i D01h PIRATION DATE D01i RELATIONSHIP TO UST FACILITY (Check One): ^ 1. OWNER ^ 2. OPERATOR ^ 3. EMPLOYEE SERVICE TECHNICIAN O 5. THIRD PARTY D01j . . _ .; -~ . , , , ~.` . ., ~ . ',IX.~:ALTERNATE, DESIGNATED OPERATOR `INFORMATI.ON'. ~: , , :,. , ; ;~: ,.,;.- _.~,: ALTERNATEESIGNATED OPERATOR NAME E i' t~o 002a PHONE (o - 70 D02b ~ ~(~88 BUSINESS NAME ~\ ~ ~ D02c MAILING OR STREET ADDRESS D02d C~TY 5 D002e STATE DON ~~' ZIP CODE D02g ICC CERT. # ( ' (..~ (- D02h EXPIRATION DATE 002i IRELATIONSHIP TO UST FACILITY (Check One): ^ 1. OWNER ^ 2. OPERATOR ^ 3. EMPLOYEE l~l /SERVICE TECHNICIAN ~ 5. THIRD PARTY D02jj (Attach an addiUonal page if necessary.) ' I certify;,that forythis facility the;inciividual(s)~I~sted~above will serve as 4Designated UST Operator(s) Ttie indiwdual(s) will conduct and,documentr ~'.; . . > :; .,, . ,.. . ,._ : ~,monthl :facili ",ins'ections and:annuaf;facili .em lo ee:trainin ~ in accordance'with':California'Gode'ofR" ulations°Title~23' Section27.150- ....: .,.o=; NAME OF TANK OWNER (Please Print) D03a `~'~'J'~JA-~1T S'/^1~ -~~r l~ SIGNATURE OF TANK OWNER ~~~ r ~ DATE ~,, r ~ ~ ~1" D03b FD 2093 (Rev.11/06)