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LOS ANGELES FIRE DEPARTMENT Application for Division 5 Permit — Atmospheric Underground Tank Fire Department Use Only LAFD Unified Program Facility ID: Permit No.

CERS ID:

Enforcement Inspector

Date Granted

Fire Station #

(The work must start within 6 mos.)

Expiration Date:

Permit Type:

(The work must be completed)

LOCATION INFORMATION Doing Business As (DBA): Address:

Number

EPA ID No. (not required for Installation or Monitoring)

Dir.

Street Name

City:

State:

St., Ave., Blvd., etc.

Phone No.:

Zip:

PROPERTY OWNER Name:

Phone Number: (

Address:

Email:

City:

State:

Print Name:

)

Zip:

Signature: LESSEE/FACILITY OWNER

Name:

Phone Number: (

Address:

Email:

City:

State:

Print Name:

)

Zip:

Signature: CONTRACTOR INFORMATION

Company Name:

Phone Number: (

Address:

Email:

City:

State:

Zip:

City Business Number:

State Contractors Number:

Print Name:

Signature: ITEM

)

Work Comp Number: Title:

PE

UST(s) Installation

5100

UST(s) Abandonment by Removal

5201

UST(s) Abandonment-In-Place

5200

UST(s) Tank Entry / Lining / Repair

5301

UST(s) Add to / Alter: Monitor / Piping / Disp.

5300

Site Assessment

5400

Emergency Plan Check / Site Assessment

5401

QTY

Please indicate payment method by checking appropriate box:

NOTES:

Credit Card

Check

UST Permit Application - 11/17  
UST Permit Application - 11/17