HomeMy WebLinkAbout2601 CHESTER AVENUEUNDERGROUND STORAGE TANK SYSTEM
OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND
UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS
For use by Undoes Member Agencies or where approvedbyyour LocalJurisdiction
Authority Cited.• Title 13, Div. 3, Ch. 16 California Code ofRegulations (CCR)
FACILITY NAME FACILITY PHONE
Lucky 7 #8 661) 836 -1794
FACILITY SITE ADDRESS CITY
2601 S Chester Ave. Bakersfield
REASON FOR SUBMITTING THIS FORM (Check One): Change ofDesignated Operator Z Update ofICC Certification Expiration Dates)
PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY
DESIGNATED OPERATOR NAME: Bruce W. Hlnsley RELATION TO UST FACILITY (Check One)
Owner Operator Employee
Scrvice Technician Third -Party
BUSINESS NAME (Ifdifferentfrom above): Advanced Compliance
DESIGNATED OPERATOR PHONE: (661) 706-4321 ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8032698 EXPIRATION DATE: 3/8/2013
ALTERNATE 1 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 (Ifdifferentfrom above):
DESIGNATED OPERATOR PHONE: ( ) ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE:
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 (lfdifferentfrom 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 Q(differentfrom 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: Saleh Alnajr
TANK OWNER TITLE: Owner
TANK OWNER SIGNATURE:
OWNER PHONE: 1) 836 -1794
DATE: Mav 4, 2012
1. Report the names) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification
information is available on -line at: www .icesafcorg/e/certsearch.htmi. 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. unidoes. org /memberstwhoregulateswhat.html. Contact information for other
local agencies within California is available at: www. swrcb. ca. gov/ cwphomc/ ust/contacts /docstlocal_agency_lisLils.
3. 23 CCR §2715(x) requires that you notify the local agency of any changes to this information within 30 days of the date of change.
UN -062 - In www.unidotaorg 09127/05
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 byyour Local Jurisdiction
Authority Cited: Title 23, Div. 3, Ch. 16 California Code ofRegulations (CCR)
FACILITY NAME FACILITY PHONE
Lucky 7 #8 661) 836 -1794
FACILITY SITE ADDRESS CITY
2601 S Chester Ave. Bakersfield
REASON FOR SUBMITTING THIS FORM (Check One): Change ofDesignated Operator Update of ICC Certification Expiration Date(s)
PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY
DESIGNATED OPERATOR NAME: Bruce W. Hensley RELATION TO UST FACILITY (CheckOne)
Owner Operator Employee
Service Technician Third -Party
BUSINESS NAME( /fdi erentfromabove): Advanced Compliance
DESIGNATED OPERATOR PHONE: (661) 706-4321 exL
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8032698 EXPIRATION DATE: 3/8%2013
ALTERNATE 1 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 Qf&fferentfromabove):
DESIGNATED OPERATOR PHONE: ( ) ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE:
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 (1fdi erentfrom 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 (1fdifferentfrom 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: Saleh Alnajr
TANK OWNER TITLE: Owner OWNER PHONE: 1) 836 -1794
TANK OWNER SIGNATURE: (f ;!i A_A__ DATE: May 4, 2012
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/certsearcb.htmi. 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.unidoes.org /members /whoregulateswhat.htmi. Contact information for other
local agencies within California is available at: www.swrcb.ca.gov /cwphome/ust/ contacts /docstiocal_agency_listxls.
3. 23 CCR §2715(x) requires that you notify the local agency of any changes to this information within 30 days ofthe date ofchange.
UN -062 -1/1 www.unidoc&org 09/22/05