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Modesto Fire Department FIRE PREVENTION DIVISION 409 12th Street, Modesto, California 95354 Tel: (209) 571-5553 Fax: (209) 544-1652 USE, DISPENSING, AND STORAGE OF LPG PERMIT APPLICATION Date Permit Starts: Date Permit Ends: (not more than one year) Name of Business: Name of Business Owner: Owner’s Mailing Address: Business Phone: 24-hour Phone: Address of LPG: • On a site diagram, label the location of each container holding more than 500 gallons by using the following numbers: CONTAINERS FOR THE USE, DISPENSING, OR STORAGE OF LPG 1. Capacity: gallons Contains: Propane Other 2. Capacity: gallons Contains: Propane Other 3. Capacity: gallons Contains: Propane Other 4. Capacity: gallons Contains: Propane Other 5. Capacity: gallons Contains: Propane Other 6. Capacity: gallons Contains: Propane Other 7. Capacity: gallons Contains: Propane Other • What will each LPG container be used for? (list the container number from above) ▪ Dispensing into portable LPG cylinders: ▪ Dispensing into LPG fueled vehicles or industrial equipment: ▪ Other (describe): The use, dispensing, and storage of LPG is regulated by 2016 California Fire Code Chapter 61, 2014 NFPA 58, and local regulations. “I certify that the information I have supplied above is true and correct and that the use, dispensing, and storage of LPG will comply with all applicable regulations.” Signature of Applicant Printed Name of Applicant Today’s Date Applicant’s Position in Business In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at Revised 6/23/20 SIGN