HomeMy WebLinkAbout1125 COFFEE ROAD (6)City of Bakersfield Fire Dept. Prevention Services
Owner Statement of Designated Underground Storage Tank(UST) Operator and
understanding of Compliance with UST Requirement
Facility Name: Chevron Station# 203576
Facility Address : 1125 COFFEE RD,
BAKERSFIELD, CA, 93308 -5747
Facility Phone# : () 661 - 5889066
PRIMARY
Facility ID: 2235
Reason for Submitting this Form (Check One)
Change of Designated Operator
a Update Certificate Expiration Date
Q Initial Submittal Of Designated Operator
DESIGNATED UST OPERATORS FOR THIS FACILITY
Designated Operator's Name : Maurice Tamamian Relation to UST Facility (Check One)
Owner =Operator mployee
5ervice Technician Third -Party
Expiration Date : 9/29/2012
Business Name (If different from above) : Chevron Products Company
Designated Operator's Phone # : (925) 842 -9002
International Code Council Certification # : 8041099 -UC
ALTERNATE1(Optional)
Designated Operator's Name : Chevron Designated Operators Relation to UST Facility (Check One)
Elowner []Dperator mployee
Elervice Technician Third -Party
Expiration Date: 11/24/2011
Business Name (If different from above) : Chevron Products Company
Designated Operator's Phone #: (925) 842 -9002
International Code Council Certification # : Chevron Addendum
ALTERNATE2(Optional)
Designated Operator's Name : Relation to UST Facility (Check One)
F7owner DoperatorEDEmployee
Elservice Technician Third -Party
Expiration Date
Business Name (If different from above)
Designated Operator's Phone #: () -
International Code Council Certification #:
NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION
WITHIN 30 DAYS OF THE CHANGE
I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as the 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 THE TANK OWNER
OR OWNER'S AGENT (Please Print) :
SIGNATURE OF TANK OWNER
OR OWNER'S AGENT (Please Print) :
Chevron product Company, Attn: Permit Desk
DATE: 12/3/2010 OWNER'S PHONE #: (925)842 -9002
Chevron Employee Designated Operator Addendum
Chevron Designated
Operator Name Phone Number ICC Certificate #
ICC Expiration
Date
Adel Amarin 909 767 -0588 8032306 -UC 10/21/2011
Edward Dahl ren 916 271 -2363 8016980 -UC 9/28/2012
Eli'a Pender raft 916 728 -1850 8033585 -UC 8/6/2011
Hady Hernandez 323 547 -0104 8041099 -UC 11/10/2011
Jan Koekkoek 760 201 -3957 8016991 -UC 817/2012
Jeremy Glick 916 985 -4471 8020701 -UC 7/2/2011
John Dale 916 217 -1373 8000863 -UC 11/24/2011
Janet Mc CI monds 925 842 -3888 5242606 -UC 3/31/2012
Maurice Tamamian 818 430 -0655 5250201 -UC 9/29/2012
Pauline S Calalan 707 315 -4737 5256925 -UC 12/5/2011
Rodne Boles Muse 909 534 -1589 5292549 -UC 1/30/2012
Michael Wilkinson 707 257 -1224 5296380 -UC 3/31/2012
Chevron Designated Operator Addendum 12- 1- 2010.xls Page 1