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HomeMy WebLinkAbout9600 BRIMHALL ROAD (5)Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: 7 -11 32376 Facility ID #: 32376 Facility Address: 9600 Brimhall Rd. BAKERSFIELD, CA 93312 Reason for Submitting this Form (Check One) Change of Designated Operator Update Certificate Expiration DateFacilityPhone #: 6615884059 Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Fredy Barrlta Relation to UST Facility (Check One) Owner Operator Employee Service Technician ® Third -Party Business Name (Ifdifferent from above): Belshire Environmental Services, Inc. Designated Operator's Phone #: (949) 460 -5200 International Code Council Certification #: 8158278 -UC Expiration Date: 5/9/2014 ALTERNATE 1 (Optional) Designated Operator's Name: refer to the backup document Relation to UST Facility (Check One) Owner Operator Employee Service Technician ® Third -Party Business Name (If different from above): refer to the backup document Designated Operator's Phone #: refer to the backup document International Code Council Certification #: refer to the backup document Expiration Date: refer to the backup document ALTERNATE 2 (Optional) Designated Operator's Name: refer to the backup document Relation to UST Facility (Check One) Owner Operator Employee Service Technician ® Third -Party Business Name (If different from above): refer to the backup document Designated Operator's Phone #: refer to the backup document International Code Council Certification #: refer to the backup document Expiration Date: refer to the backup document 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 (Please Print): Stephen K. Boyd SIGNATURE OF TANK OWNER: .96A, 1:• DATE: 6/1/2012 OWNER'S PHONE #: (714) 771 -5484 NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov /ust/contacts /cuoa agys.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004 belshi"re environmental services, inc. 25971 Towne Centre Drive, Foothill Ranch, CA 92610 Designated Operator Alternate List Name 4= "Y: ui.. y ICCGert# Expiration 5 ,PhoneS,A Jhustin Abeleda 8036229 -UC 9/24/2013 949) 460 -5200 Jeffrey Badders 5252456 -UC 10/7/2013 949) 460 -5200 Fredy Barrita 8158278 -UC 5/9/2014 949) 460 -5200 James Beck 8159612 -UC 5/18/2014 949) 460 -5200 Oliver Cruz 5244318 -UC 9/8/2012 949) 460 -5200 Andy DeGregorio 8019630 -UC 10/4/2012 949) 460 -5200 Jesse Diaz 5320089 -UC 8/23/2013 949) 460 -5200 Ricky Diaz 8102023 -UC 2/15/2013 949) 460 -5200 Jackie Dougherty 5234433 -UC 7/14/2012 949) 460 -5200 Glenda Esteban 8018547 -UC 9/8/2012 949) 460 -5200 Cheron Flores 8019649 -UC 10/8/2012 949) 460 -5200 Grasiela Gama 8022001 -UC 12/14/2012 949) 460 -5200 Angelo Georgetti 8027546 -UC 3/22/2013 949) 460 -5200 Kris Gondrez 8115255 -UC 5/26/2013 949) 460 -5200 Noah Henning 8157941 -UC 517/2014 949) 460 -5200 Michael Holkko 8025470 -UC 1/10/2014 949) 460 -5200 Kevin Hom 8142199 -UC 1/6/2014 949) 460 -5200 Richie LeClair 8155188 -UC 4/17/2014 949) 460 -5200 Santi Luangpraseut 8057544 -UC 2/1/2014 949) 460 -5200 Andrew Marvin 8146893 -UC 2/16/2014 949) 460 -5200 Jack Nestler 8079218 -UC 8/31/2012 949) 460 -5200 Cory Nicholson 8020120 -UC 10/8/2012 949) 460 -5200 Chukwuemeka Odunze 8105942 -UC 3/18/2013 949) 460 -5200 Clarinda Olson 5244506 -UC 2/2/2013 949) 460 -5200 Cristina Pena 8010939 -UC 5/7/2014 949) 460 -5200 Spencer Platler 8014664 -UC 6/16/2012 949) 460 -5200 Douglas Shearer 5240897 -UC 7/14/2012 949) 460 -5200 Roman Shekhter 8035361 -UC 8/16/2013 949) 460 -5200 Jonathan Shisler 8146894 -UC 2/16/2014 949) 460 -5200 Greg Vierra 5317332 -UC 7/19/2013 949) 460 -5200 J1