Loading...
HomeMy WebLinkAbout2505 HALEY Street_UST MINOR MOD 5.10.10File Number: 1DOaS`f 0 Date Received: In Address: Bakersfield, CA 933 ` Business Name: Comments: - -3 l<. s 1. 2. 3. 4. � Yy INSPECTION LOG Date Time SYSTEM: BUILDING SQUARE FEET: New Mod. ®R;M22y L�^/L' ❑ ❑ Commercial Hood System Building Sq. Feet: ❑ ❑ Fire Alarm System : Calculation Bldg. Sq. Ft: ❑ ❑ Fire Sprinkler System ❑ ❑ Sprpy Finish System ❑ ❑ Aboveground Storage Tank / C/ ❑ Underground Storage Tank minor modification Underground Storage Tank removal Underground Storage Tank ❑ ❑ Other: Comments: - -3 l<. s 1. 2. 3. 4. � Yy INSPECTION LOG Date Time r Signature Signature �RES5raet� �pc's T ip PocsschleC+ a 1J�Fl lU C� ®R;M22y L�^/L' IE rz /rL /�v Ft? C-, r N?i r Signature Signature �RES5raet� �pc's IE i ®R iota ENHANCED LEAK DETECTION UST System Post Installation Test Report ELD Test Date: Customer: Location: December 17, 2010 Ralphs / Food 4 Less / Foods Co Fuel 1100 W Artesia blvd Compton, CA 90220 Foods Co Fuel 2505 Haley St. Bakersfield, CA Tested By: CGRS, Inc. 5444 Dry Creek Road Sacramento, CA 9583 Project No: 6- 10238 - 12720 -8462 RFv1sed ,"-9/2,V �o CG - io 5444 Dry Creek Road Sacramento, CA 95838 cn„wivicec.cac.onccnaH 800-288-2657 Test Certification Post Installation Enhanced Leak Detection (ELD) Location: CGRS Project No: 6- 10238- 12720 -8462 Foods Co Fuel Test Date: December 17, 2010 2505 Haley St. CGRS Techs: Bakersfield, CA This document certifies that the UST systems listed below at the above referenced location have been tested and passed the iota® VaporTite V005 tightness test. CGRS further certifies that the iota® VaporTite V005 meets the post installation testing requirements for post installation testing for newly installed underground storage tank systems as per the California Health and Safety Code, Chapter 6.7, section 25290.10)(1). Post Installation ELD Test Results 87 Unleaded Primary Containment System PASS Diesel Primary Containment System PASS 91 Premium Primary Containment System PASS IOTA Tech Signature: Sergio Nung CA Tester No #06 -1 12/17/10 Date Reviewed by: 12/17/10 Chris Mur_hy- CA Operations Ma age Date iota CG 5444 Dry Creek Road Sacramento, CA 95838 800- 288.2657 Final ELD Test Project Worksheet Final Test Date 12/1712010 IOTA Terhniria— Cumin Kh'— Site Information Length in. Installation Contractor Information Facility: Foods Co Fuel Customer Name : B&T construction Address: 2505 Haley St. Address: 630 south frontage rd City, State, Zip: Bakersfield, CA City, State, Zip: Nipomo, CA 93444 County: Kern Contact: Keith Slocum CUPA Contact: Barbara D. Houghton Telephone /Email 805- 929- 8944/keith @bandtgroup.com CUPA Phone: 661 862 -8743 / hazmat ro ram co.kern.ca.us S3 42 84 TANKS Tank No. Capacity al. Product Type Manufacturer Brine Test Result lank 1 ZUK a7 Unleaded DW Fiberglass Xerxes Yes PASS Tank 2 10K Diesel DW Fiberglass Xerxes Yes 'PASS Tank 3 8K 91 Premium DW Fiberglass Xerxes Yes PASS Junction Boxes with Tank Connection Description Test Resuh S Tank Probe and Turbine J -Box Open During Test PASS S Tank Probe and Turbine J -Box Open During Test _ PASS S Tank Probe and Turbine J -Box Open During Test PASS UDCs Length in. Width in. COMPONENTS IN CONTAINMENT Volume gal. Tank Top Sums Diameter in. Depth (in. ) Volume (gal. ) Description Test Result S1 42 84 504 87 TS PASS S2 42 84 504 87 FS PASS S3 42 84 504 91 TS PASS S4 42 84 504 91 FS PASS S5 42 84 504 DSL TS PASS S6 42 84 504 DSL FS PASS " Junction Boxes with Tank Connection Description Test Resuh S Tank Probe and Turbine J -Box Open During Test PASS S Tank Probe and Turbine J -Box Open During Test _ PASS S Tank Probe and Turbine J -Box Open During Test PASS UDCs Length in. Width in. Depth in. Volume gal. Description Test Result UDC1 42 20 32 116 Bravo PASS UDC2 42 20 32 116 Bravo PASS UDC3 42 20 32 116 Bravo PASS UDC4 42 20 32 116 Bravo PASS UDC5 42 20 32 116 Bravo PASS UDC6 42 20 32 116 Bravo PASS UDC7 42 20 32 116 Bravo PASS Transition Sump Length in. Width in. Depth in. Volume al. Description Test Result TS1 28 24 32 93 Bravo PASS 87 Unleaded Smith DW Fiberglass 2" 279 PASS Diesel Smith DW Fiberglass 2" 173 PASS 91 Premium Smith DW Fiberglass 2" 269 PASS Vent Piping Manufacturer Type Size (in.) Length ft. Test Result 87 Smith DW Fiberglass 2" 65 PASS 91 Smith OW Fiberglass 2" 81 PASS Diesel - Smith DW Fiberglass 2" 71 PASS Va or Piping Manufacturer Type Size in. Length R. Test Result 87 Smith DW Fiberglass 3" 301 PASS 91 Smith DW Fiberglass 3" 10 PASS 12117/2010 06-1727 12117/2010 Reviewed B Date IOTA Tech Si ature 1 0 CA License No. Date CONSTRUCTION PERMIT Application Number . . . . Property Address . . . . . . ATN (11 Digits): Application type description Subdivision Name . . . . . . Property Use . . . . . . . . Application valuation . . . . Owner ------------------ --- - -- STATE STREET BANK & TR CO TRS P O BOX 54143 LOS ANGELES CA 90054 BAKERSFIELD FIRE DEPARTMENT PREVENTION SERVICES 6 R S F I D 1501 TRUXTUN AVENUE, 1sT FLR FIRE BAKERSFIELD, CA 93313 A R TNI T Office Phone: (661) 326 -3979 10- 10000143 Date 5/20/10 2505 HALEY ST * 126 - 360- 07 -00 -3 FIRE DEPT 0 Contractor --------------- --- -- - - -- OWNER ---------------------------------------------------------------------------- Permit . . . . . . UNDGRND STR TANK INSTALL /INSP Additional desc . . Phone Access Code . 1002989 Permit Fee . . . . 439.00 Plan Check Fee 439.00 Issue Date . . . . 5/20/10 Valuation . . . . 0 Expiration Date . . 11/16/10 ---------------------------------------------------------------------------- Fee summary ----------- - - - - -- Charged ---- -- - - -- -- Paid Credited -- - - - - -- ---- Due Permit Fee Total 439.00 - - - 439.00 - -- ---- .00 - - - - -- .00 Plan Check Total 439.00 439.00 .00 .00 Grand Total 878.00 878.00 .00 .00 CALL FOR INSPECTION (661) 326 -3979 Please state the Permit Number, the Job address, and the Type of Inspection. Requests for inspections should be made at least 48 hours in advance. DECLARATIONS Permit is issued in accordance with all applicable Federal, State and Local Ordinances. The permittee has properly signed and dated the reverse side of this form. This Permit expires after180 days of inactivity. I have reviewed the above application, and find it to be correct/complete. Permittee: Date: HAZARDOUS MATERIALS STATEMENT _ Yes _ No Will the applicant or future occupant handle hazardous material or a mixture containing a hazardous material equal to or greater than the amounts specified on the list of extremely hazardous substances? See checklist for guidelines. Yes _ No Will the proposed building or modified facility be within 1000 feet of the outer boundary of a school? Yes _ No Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the Kern County Air Pollution Control District ( KCAPCD) or from the Bakersfield Fire Dept? See checklist for guidelines. _ Yes _ No I have read the Hazardous Material Guide and KCAPCD Permitting Checklist. I understand my requirements under the Calif. Health and Safety Code Sec. 6.95 and Calif. Govt. Sec. 65850 and the requirements of the City of Bakersfield Fire Dept. regarding hazardous materials. Owner or Authorized Agen4" =_ -_ _ � ` : hone No. _ Date DECLARATIONS: The declarations below are mandated by the State of California under Section 19825 of the Health and Safety. Code. LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of the Division 3 of the Business and Professions Code and my license is in full force and effect. Lic. Class Lic. No. Exp. Date Contractors Signature Date OWNER- BUILDER DECLARATION I hereby affirm that under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Sec. 7031.5 Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 commencing with Section 7000 of Division 3 or the Business and Professions Code) or that he or she is exempt there from and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)): I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he or she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such project with a contractor(s) licensed pursuant to the Contractor License Law). I am exempt under Sec. B. & P. C. for the reason Owner Signature n_ !j�,g �- ,, _ I - = fF ` =' a ` °�. _ Date WORKERS COMPENSATION DECLARATION I hereby affirm that under penalty of perjury one of the following declarations: Carrier I have and will maintain a certificate of consent to self - insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Policy No. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions. Applicant: Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000) IN ADDITION TO COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097 Civ. C.) Lenders Name Lenders Address I certify that I have read this application and state that the information contained herein is correct. I agree to comply with all city ordinances and state laws relating to building construction and hereby authorize representatives of the city to enter the above mentioned - property for inspection purposes. Signature of Applicant or Agent _ _ -- Date CONSTRUCTION PERMIT Application Number . . . . . Property Address . . . . . . ATN (11 Digits): Application type description Subdivision Name . . . . . . Property Use . . . . . . . . Application valuation . . . . Owner ------------------ -- - - -- SMITHS FOOD & DRUG CENTER INC 1550 REDWOOD RD SALT LAKE CITY UT 84104 BAKERSFIELD FIRE DEPARTMENT PREVENTION SERVICES X S P I D 1501 TRUXTUN AVENUE, 1sT FLR FIRE BAKERSFIELD, CA 93313 IRTNA qr Office Phone: (661) 326 -3979 10- 10000142 Date 5/20/10 2505 HALEY ST 126- 360- 06 -00 -0 FIRE DEPT 0 Contractor ------------------ - - - - -- OWNER ---------------------------------------------------------------------------- Permit . . . . . . UNDGRND STR TANK INSTALL /INSP Additional desc . . Phone Access Code . 1002955 Permit Fee . . . . 439.00 Plan Check Fee 439.00 Issue Date . . . . 5/20/10 Valuation . . . . 0 Expiration Date 11/16/10 Fee summary ---------- - - - - - -- Charged Paid Credited Due Permit Fee Total ---- - -- - -- -- 439.00 -- - -- - -- ---- -- ---- 439.00 ---- .00 - - - - -- .00 Plan Check Total 439.00 439.00 .00 .00 Grand Total 878.00 878.00 .00 .00 CALL FOR INSPECTION (661) 326 -3979 Please state the Permit Number, the Job address, and the Type of Inspection. Requests for inspections should be made at least 48 hours in advance. DECLARATIONS Permit is issued in accordance with all applicable Federal, State and Local Ordinances. The permittee has properly signed and dated the reverse side of this form. This Permit expires after180 days of inactivity. I have reviewed the above application, and find it to be correct/complete. Permittee: Date: HAZARDOUS MATERIALS STATEMENT Yes _ No Will the applicant or future occupant handle hazardous material or a mixture containing a hazardous material equal to or greater than the amounts specified on the list of extremely hazardous substances? See checklist for guidelines. Yes _ No Will the proposed building or modified facility be within 1000 feet of the outer boundary of a school? Yes _ No Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the Kem County Air Pollution Control District ( KCAPCD) or from the Bakersfield Fire Dept? See checklist for guidelines. Yes _ No I have read the Hazardous Material Guide and KCAPCD Permitting Checklist. I understand my requirements under the Calif. Health and Safety Code Sec. 6.95 and Calif. Govt. Sec. 65850 and the requirements of the City of Bakersfield Fire Dept. regarding hazardous materials. Owner or Authorized Agent :1<; lc °a > : _: F "= Y ' %= -:' =;i:: hone No. Date DECLARATIONS: The declarations below are mandated by the State of California under Section 19825 of the Health and Safety Code. LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of the Division 3 of the Business and Professions Code and my license is in full force and effect. Lie. Class Lie. No. Exp. Date Contractors Signature Date OWNER - BUILDER DECLARATION I hereby affirm that under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Sec. 7031.5 Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 commencing with Section 7000 of Division 3 or the Business and Professions Code) or that he or she is exempt there from and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)): I, as owner of the property or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he or she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such project with a contractor(s) licensed pursuant to the Contractor License Law). I am exempt under Sec. B. & P. C. for the reason Owner Signature °4x _ x.;a & : _> . : , ::: �: =fit= `�t;• `'= ri�_,...M. �-��: - Date WORKERS COMPENSATION DECLARATION I hereby affirm that under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self - insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy No. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions. Applicant: _ Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000) IN ADDITION TO COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097 Civ. C.) Lenders Name Lenders Address I certify that 1 have read this application and state that the information contained herein is correct. I agree to comply with all city ordinances and state laws relating to building constriction and hereby authorize representatives of the city to enter the above mentioned- property for inspection purposes. Signature of Applicant or Agent " _ _ - � _ �-,� _ �& A Date ,44 ne Reirgroup Architecture • Engineering • Planning • Project Management LETTER OF.TRANSMITTAL s TO: City of Bakersfield Fire Department (UST) 2101 H Street Bakersfield, Ca.. DATE: May 10, 2010 PROJECT: Foods Co LOCATION: 2505 Haley St. Bakersfield, Ca. ATTN: Howard Wines JOB NO: 13280 PHONE: 661 - 326 -3979 REGARDING: Fuel Permit (Please include phone no. for all Federal Express) WE ARE TRANSMITTING FOR YOUR THE FOLLOWING ACTION fiedlergroup.com ❑ . -. Per your.request. ❑ - Approval ❑ Prints ❑ Approve &.Return ❑ As requested by: ❑ Revision /Comments ❑ Sepias ❑ Approve Corrections & ❑ Use ❑ Originals Return ❑ Submitted Via: ❑ Distribution ❑ Disks ❑ Correct & Return Fed Ex Priorty ❑ Information /Files ❑ Other: COPIES 'DATE OR NO. Ms DESCRIPTION 2 Sets Fuel Plans 2 Checks $ 1923 and $ 711 REMARKS: For Fuel Permit COPIES TO: FROM: Wayne Watkins 2322 West Third Street • Los Angeles, California 90057 -1906 • Phone: 213- 381 -7891 • Fax: 213- 381 -1517 fiedlergroup © 2010 L \outlookfolders \1000 Administration Procedures \1100 Forms \1100 Letter of Transmittal.DOC Wayne Watkins Project Manager e lergroup ANdtectwe • Eyynaenng • Planning' Prolecl Ma�gemert . ,. 2322 West Third Street Los Angeles, CA 90057 -1906 Cell: 909 -472 -1954 Fax: 213 -381 -1517 fiedlergroup.com wayne.watkins@iiedlergroup.com J BILLING & PERMIT STATEMENT A BAKERSFIELD FIRE DEPARTMENT n s R S r, I E n Prevention Services . a FIRE a. PERMIT # p: ®��p�y p 2101 H Street Bakersfield, CA 93301 Phone: 661- 326 -3979 o Fax: 661 -852 -2171 All permits must be reviewed, stamped, and approved PRXOR TO BEGIIiO MIING WORK. PERMIT TYPE FEE;C)�LC6� .p Alarm - New & Modification (minimum charge) $280 ° . ❑ Over 10,000 sq. ft $0 .028 x'sq ft TOIAFORMAT164, Sprinkler - New & Modification (minimum charge) $280 LOCATION OF PROJECT 2- o I-I- cz�+ 1 PROPERTY OWNER 5m I h Q rrJ ❑ STARTING 1V i 1 COMPLETION DATE -3� � t D NAME 84 ❑ Commercial Hood (New & Modification) PRO Cr NAME ADDRESS Z �- I S PHONE # $58 2Z� r�' - �z -I s PROJECT ADDRESS (2 S�} . $a k•a rs F rL� crnr STATE CA ZIP CODE 82 o- Additional Tank ATI $96 /tank Q 82 ❑ Aboveground Storage Tank (Removal /Mod /Inspect) ATR $109 /tank 82 Underground Storage Tank (Installation /Inspection). NI $878 /tank CONTRACTOR NAME 82 CA LICENSE # TYPE OF LICENSE EXPIRATION DATE PHONE # CONTRACTOR COMPANY NAME ❑ Underground Storage Tank (Minor Modification) MTM $167 /site FAX # 82 ADDRESS Underground Storage Tank (Removal) TR CITY ZIP CODE ❑ All permits must be reviewed, stamped, and approved PRXOR TO BEGIIiO MIING WORK. PERMIT TYPE FEE;C)�LC6� .p Alarm - New & Modification (minimum charge) $280 ° . ❑ Over 10,000 sq. ft $0 .028 x'sq ft ❑ Sprinkler - New & Modification (minimum charge) $280 ❑ Over 10,000 sq ft $0.028 x sq ft ❑ Minor Sprinkler Modification ( <10 heads) $96 (inspection only) 84 ❑ Commercial Hood (New & Modification) $470 ❑ Additional hood $58 ❑ Spray Booth (New & Modification) $470 98 ❑ Aboveground Storage Tank (1 inspection per installation). AST $180 /tank 82 o- Additional Tank ATI $96 /tank 82 ❑ Aboveground Storage Tank (Removal /Mod /Inspect) ATR $109 /tank 82 Underground Storage Tank (Installation /Inspection). NI $878 /tank 3 82 0, Underground Storage Tank (Modification) MOO $878 1site 82 ❑ Underground Storage Tank (Minor Modification) MTM $167 /site 82 ❑ Underground Storage Tank (Removal) TR $573 /tank 84 ❑ Mandated Leak Detection (test) /Fuel Mont Cert/S6989 TT NOTE: $96 /hr for ea type of test/per site even if scheduled at he same time $96 /hr (2 hrs minimum) =$192 82 ❑ Oil well (Installation, Inspection, or re- inspection) . X $96 /hr 82 ❑ Tent # $96 /tent 84 ❑ After -hours inspection fee $121 /hr (2 hrs minimum) =$242 ❑ Pyrotechnic (1 permit per event, plus an inspection fee of $96 /hr during business hours) PY NOTE: After hours Pyrotechnic event inspection is @ $121 /hr _ $96 /hr + (5 hrs min standby fee /insp)= $576 5 hrs min standby fee ins = 605 84 ❑ Re- inspection /Follow -up Inspection $96 1hr 84 ❑ Portable i_PC (Propane): # of Cages? $96 /hr 84 ❑ Explosive Storage $266 84 ❑ Copying & File Research (File Research fee $50 /hr) $0.25 /page 84 ❑ Miscellaneous 84 a UNDERGROUND STORAGE TANK PERMIT APPLICATION TO CONSTRUCT - INSTALL NEW TANK (NEW FACILITY) /NEW, TANK INSTALL (EXISTING FACILITY) /MOD -MINOR MOD Permit # BAKERSFIfELD FIRE DEPARTMENT Prevention Services 2101 H Street a s ESL D Bakersfield, CA 93301 FlRR Phone: 661 -326 -3979 ® Fax: 661 -852 -2171. a / rH r V Page 1 of i TYPE OF APPLICATION: ❑ NEW TANK INSTALL /NEW FACILITY (CHECK ONF ONLY) ❑ MODIFICATION OF FACILITY • NEW TANK INSTALL /EXISTING FACILITY • MINOR MODIFTCATION OF FACILITY STARTING DATE/ PROPOSED r o ' :�5-U we �.� 20I0 -- 3V O COMPLETION DATE �U L ?jo 2,o ( O FACILITY N*h 3 EKISTI G FACILITY PERMIT # FACILITY AD(4 5$0� + '^ 5 r ,S lT/%- l CITY j7� 1 ' Trlc'c rs ZIP CODE TYPE OF SINE � S APN # TANK OW ER pp ' pe�GC, LO PHONE 0 ADDRES CITY L) . %kr 44.5 - A- (',, k) ZIP CODE CONTRACTOR CA LICENSE # ICC # ADDRESS CITY ZIP CODE PHONE # BAKERSFIELD CITY BUSINESS LICENSE # WORKMANS COMP # JINSURER BRIEFLY DESCRIBE THE WORK TO BE DONE: �-i' A L L— �ci1 l} Q . �— I c-+ AC, I - �i/a�✓o 10 5 WATER TO FACILITY PROVIDED BY DEPTH TO GROUND ATER SOIL TYPE EXPECTED AT SIFE # OF TANKS TO BE IN ALLED ARE HEY FOR MOTOR FUEL? YES ❑ NO SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE? ❑ YES ❑ NO THIS SECTION IS FOR STORAGE TANK IDENTIFICATION TANK 4t VOLUME UNLEADED REGULAR PREMIUM DIESEL OTHER O 00 io Dan Tank Testing Company �- g . 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