HomeMy WebLinkAbout1520 20TH STREET (7)BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK SYSTEM
OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND
UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS
For use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Authority Cited.- Title 23, Div. 3, Ch. 16 California Code ofRegulations (CCR)
FACILITY NAME FACILITY PHONE
AT &T CORP (CAK010) 559) 228 -7056
FACILITY SITE ADDRESS CITY
1520 20th St. Bakersfield
REASON FOR SUBMITTING THIS FORM (Check One): Change of Designated Operator E Update of ICC Certification Expiration Date(s)
PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY
DESIGNATED OPERATOR NAME: Kirk Fowler RELATION TO UST FACILITY (Check One)
Owner Operator Employee
Service Technician ® Third -Party
1USINESS NAME (Ifdiiferenl from above): Tait Environmental Services
DESIGNATED OPERATOR PHONE: (714) 920 -8201 ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243705-UC EXPIRATION DATE: 8/ 20/2012
ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional)
DESIGNATED OPERATOR NAME: See Attachment RELATION TO UST FACILITY (Check One)
Owner Operator Employee
Service Technician ® Third -Party
BUSINESS NAME (Ifdiiferenrfrom above): Tait Environmental Services
DESIGNATED OPERATOR PHONE: ( ) ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: See Attachment EXPIRATION DATE: See Attachment
ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional)
DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One)
Owner Operator Employee
Service Technician Third -Party
BUSINESS NAME (Ift1iferenifrom above):
DESIGNATED OPERATOR PHONE: ( ) ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE:
ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional)
DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One)
Owner Operator Employee
Service Technician Third -Party
BUSINESS NAME (Ifdiiferenifrom above):
DESIGNATED OPERATOR PHONE: ( ) ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE:
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) through (f). Furthermore, I understand and am
in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks.
TANK OWNER NAME: Steven J Hall
TANK OWNER TITLE:
Manager EH &S OWNER PHONE: 214 -464 -3131
TANK OWNER SIGNATURE: DATE: August 30, 2010
INSTRUCTIONS
1. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available on -line at:
www .iccsafe.org/e /certsearch.html. Search for "California UST System Operators."
2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on -line
at: www.unidocs.org /members /wheregulateswhaLhtmi. Contact information for other local agencies within California is available at:
www.swrcb.ca.gov /cwphome/ust/ con tacts /docs/local_agen cy_list.xIs.
3. 23 CCR §2715(a) requires that you notify the local agency of any changes to this information within 30 days ofthe date of change.
UN -062 - 1/74 www.unidocs.org 09/22/05
jTA I T
M131RIG TO TH0 COLCLING3
ICC Certified Designated Operators
Designated Operator Program Director: Paul McCarter — 714.560.8200
Name ICC Certification # Exp. Date Phone
Butler, Goldie 5245828 -UC 11/04/2010 714.920.7818
Brehmer, Scott 8013043 -UC 07/14/2012 714.720.2111
Dawson, Peter 5280692 -UC 01/13/2012 714.920.8238
Durham, Eric 5240929 -UC 12/30/2011 714.920.8239
Ericsen, Timothy 5223666 -UC 02/17/2011 714.560.8605
Fowler, Kirk 5243705 -UC 08/20/2012 714.920.8201
Grylls, Gloria 8020100 -UC 11/01/2010 714.920.7970
Hall, Ian 5311539 -UC 03/02/2012 714.920.8215
Holbrook, Phil 5252931 -UC 10/31/2010 714.920.8236
Koffel, George 5247982 -UC 12/11/2010 714.920.5387
Kostel, Timothy 5248172 -UC 07/28/2012 714.920.8214
Riggins, Larry 5243198 -UC 09/26/2010 714.920.5477
Rogers, Brian 5248762 -UC 11/25/2010 714.920.7661
Thruston, Yolanda 8020116 -UC 11/11/2010 714.920.7056
Yellish, John 5249179 -UC 11/21/2010 714.920.8189
Last Updated 8/30/2010