LOS ANGELES FIRE DEPARTMENT Email: lafdustplancheck@lacity.org 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
CREDIT/DEBIT CARD PAYMENT SERVICE FEE ADVISORY: EFFECTIVE JULY 1, 2020, CREDIT OR DEBIT CARD PAYMENTS ARE SUBJECT TO A NON- REFUNDABLE 2.70% SERVICE FEE WHICH WILL BE COLLECTED AND PROCESSED AS A SEPARATE TRANSACTION BY OUR THIRD PARTY PAYMENT PROCESSOR, ELAVON INC. THIS RATE IS SUBJECT TO CHANGE BASED ON CREDIT/DEBIT INTERCHANGE RATE.