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: (
)
Phone Number: (
)
Company Name:
Phone Number: (
)
Address:
Email:
Address: City:
State:
Print Name:
Zip:
Signature: LESSEE/FACILITY OWNER
Name: Address: City:
State:
Print Name:
Zip:
Signature: CONTRACTOR INFORMATION
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