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HomeMy WebLinkAbout100 OSWELL STREET (4)Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: GasCo Food Mart Facility ID #: Facility Address: 100 S. OswelI St.. Bakersfield, CA 93307 Kern County) Reason for Submitting this Form (Check One) x Change of Designated Operator Update Certificate Expiration DateFacilityPhone #: 661- 861 - 9769 Designated UST Oyerator(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 (Ifdifferentfrom 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 (Ifdifferentfrom 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) Owner Operator Employee Service "technician x Third -Party Business Name (Ifdiiferent from above): Confidence USTServices, 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 (Plea SIGNATURE OF TANK OWNE DATE: 04/13/2012 OWNER'S PHONE #: 661 - 366 -2511 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,gQv /ust/contacWcupa p&s.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004