HomeMy WebLinkAboutOWNER STATEMENTS OF DESIGNATED UST 3-29-12Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Proactive Properties, Inc. dba White Lane Chevron
Facility ID #:
Facility Address: 2525 White Lane, Bakersfield, CA 93304
Reason for Submitting this Form (Check One)
(City)
x Change of Designated Operator
F1 Update Certificate Expiration Date
Facility Phone #: 661- 832 -9781
Designated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Catherine C. Riccomini
Relation to UST Facility (Check One)
Owner ❑ Operator ❑ Employee
❑ Service Technician X Third -Party
Business Name (If difjerenl from above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8018933 -UC
Expiration Date: September 8, 2012
ALTERNATE 1 (Optional)
Designated Operator's Name: Frank Landa
Relation to UST Facility (Check One)
❑ Owner ❑ Operator ❑ Employee
❑ Service Technician X Third -Party
Business Name (If diflerenl from above): Confidence UST Services, inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8018524 -UC
Expiration Date: July 12, 2013
ALTERNATE 2 (Optional)
Designated Operator's Name: Eric R. Santos
Relation to UST Facility (Check One)
El Owner ❑ Operator ❑ Employee
❑ Service Technician x Third -Party
Business Name (lf Q erenl from above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8015508 -UC
Expiration Date: December 7, 2013
I certify that, for the facility indicated at the top of this page, the individual(s) listed above will
serve as Designated UST Operator(s). The individual(s) will conduct and document monthly
facility inspections and annual facility employee training, in accordance with California Code of
Regulations, title 23, section 2715(c) - (f).
Furthermore, I understand and am in compliance with the requirements (statutes,
regulations, and local ordinances) applicable to underground storage tanks.
NAME OF TANK OWNER (Please
SIGNATURE OF TANK OWNER:
DATE: '— c D OWNER'S PHONE #: 805_444AM
NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER
RESOURCES CONTROL BOARD). THE LOCAL AGENCY LIST IS AVAILABLE AT:
www. waterboards .ca.gov /ust /contacts/cupaa agys.lihnl.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
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Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Proactive Properties, Inc. dba White Lane Chevron
Facility ID #:
Facility Address: 2525 White Lane, Bakersfield, CA 93304
Reason for Submitting this Form (Check One)
(City)
x Change of Designated Operator
R Update Certificate Expiration Date
Facility Phone #: 661 -832 -9781
Designated UST Operator(s) for this Facility
ALTERNATE 3 (Optional)
Designated Operator's Name: Bryan A. Self
Relation to UST Facility (Check On(-,)
Owner ❑ Operator ❑ Employee
❑ Service Technician X Third -Party
Business Name (If different ftonn above): Calfidence UST Services, Inc.
Designated Operator's Phone #: 800 -339 -9930
International Code Council Certification #: 8022804 -UC
Expiration Date: November 19, 2012
ALTERNATE 4 (Optional)
Designated Operator's Name: Kristopher M. Kerns
Relation to UST Facility (Check One)
❑ Owner ❑ Operator ❑ Employee
❑ Service Technician X Third -Party
Business Name (If different from above): Coy f dente UST Services, Inc.
Designated Operator's Phone #: 800 -339 -9930
International Cale Council Certification #: 5264406 -UC
Expiration Dale: July 19, 2013
ALTERNATE 5 (Optional)
Designated Operator's Name: Douglas M. Young
Relation to UST Facility (Check One)
❑ Owner ❑ Operator ❑ Employee
❑ Service Technician X Third -Party
Business Name (If differentfi•orn above): Confidence UST Services. Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8043499 -UC
Expiration Date: September 8, 2012
I certify that, for the facility indicated at the top of this page, the individual(s) listed above will
serve as Designated UST Operator(s). The individual(s) will conduct and document monthly
facility inspections and annual facility employee training, in accordance with California Code of
Regulations, title 23, section 2715(c) - (fl.
Furthermore, I understand and am in compliance with the requirements (statutes,
regulations, and local ordinances) applicable to underground storage tanks.
NAME OF TANK OWNER (Please Print): l U »–
SIGNATURE OF TANK OWNER: — 6�
DATE: OWNER'S PHONE #: 805--#44--#2"29
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NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER
RESOURCES CONTROL BOARD). THE LOCAL AGENCY LIST IS AVAILABLE AT:
www. waterboards .ca.gov /ust /contacts/cupa agys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
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"COMPLIANCE WITH CONFIDENCE"
March 29, 2012
CITY OF BAKERSFIELD
Fire Prevention Services
2101 -H- Street
Bakersfield, CA 93301
To Whom It May Concern:
Enclosed please find completed Owner Statements of
Designated UST Operator and Understanding of and Compliance with
UST Requirements re Change of Designated Operator for White Lane
Chevron.
Please feel free to contact me should you have any
questions. Thank you.
Enclosure
CONFIDENCE UST SERVICES, INC.
W�
Cheri Young
Vice - President
16250 Meacham Road • Bakersfield, CA 93314
(661) 631 -3870 or (800) 339 -9930
FAX (661) 587 -9758