Permit Number:.
Date Issued:
Tank Installation/Removal Permit Application
Revision Date:
Owner:
Contractor:
Address:
Address:
Telephone:
Telephone No.:
Work Site Address:
License No.:
WHEN CHANGING CONTRACTORS YOU MUST NOTIFY THIS OFFICE
Agent Signature
INSTALLATION INFORMATION
Approximate Installation Date
Check One
Number of Tank(s) Installed
Underground
Construction if Tank(s) Installed
Capacity of Tank(s) Installed
Aboveground
Contents of Tanks(s) Installed
REMOVAL INFORMATION
Approximate Removal Date
Check One
Number of Tank(s) Removed
Underground
Construction if Tank(s) Removed
Capacity of Tank(s) Removed
Aboveground
Contents of Tanks(s) Removed
Is removal of tank prompted by knowledge of a leak? Yes No
Durin
Installation/Removal
if a leak is discovered contact the Fire Marshal’s Office IMMEDIATELY
FOR OFFICE USE ONLY
Reviewer’s Signature:
Date
Permit Cost $
Inspection Date:
Pass Fail Inspector’s Signature:
Reviewer’s Comments:
CALL FOR REQUIRED INSPECTIONS (215) 633-3617
BENSALEM TOWNSHIP
Fire Marshal’s Office
Office (215) 633-3617 ● Fax (215) 633-3662
For Ins
ections Call
215
633-3644
CERTIFICATION IN LIEU OF OATH:
(Complete for Minor Work and Small Job Only)
I hereby certify that the proposed work is authorized
by the owner of record and I have been authorized
by the owner to make this application as his agent.
Rev. 1/2009
