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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