HomeMy WebLinkAbout928 FLOWER STREET (4)J
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Flower Street Mini Mart Facility ID #:
Facility Address: 928 Flower Street
Bakersfield, CA 93305
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: (661) 328 -0732
Designated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Catherine C. Riccomini Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (Ifdiferentfrom above): Confidence USTSerince<c, Inc.
Designated Operator's Phone #: 800 -339 -9930
International Code Council Certification #: 8018933 -UC Expiration Date: September 8, 2012
ALTERNATE I (Optional)
Designated Operator's Name: Frank Landa Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (/fdii erenlfrom above): Confidence UST Servicee, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8018524 -UC Expiration Date: July 12, 2013
ALTERNATE 2 (Optional)
Designated Operator's Name: Eric R. Santos Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (Ifdi[ %ren! from above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8015508 -UC Expiration Date: December 7, 2013
I certify that, for the facility indicated at the top ofthis 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):
SIGNATURE OF TANK OWNER:
DATE: r OWNER'S PHONE #: (661) 328 -0732
NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER
RESOURCES CONTROL BOARD). THE LOCAL AGENCY LIST IS AVAILABLE AT:
www. waterboardswww .waterboards.ca =,ov /ust/ contacts /cupa agys .litml =.ov /ust /contacts/cupa agys.litml.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Flower Street Mini Mart Facility ID #:
Facility Address: 928 Flower Street
Bakersfield, CA 93305
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: (661) 328 -0732
Designated UST Operator(s) for this Facility
ALTERNATE 3 (Optional)
Designated Operator's Name: Bryan A. Self Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (Ifdifferentfrom above): Confidence UST Senncev, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8022804 -UC Expiration Date: November 19, 2012
ALTERNATE. 4 (Optional)
Designated Operator's Name: Kristopher M. Kerns Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (ifdifferentfrom above): Confidence USTSerince<v, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 5264406 -UC Expiration Date: July 19, 2013
ALTERNATE 5 (Optional)
Designated Operator's Name: Douglas M. Young Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (l( differentfrown above): Confidence USTServices, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 8043499 -UC Expiration Date: September 8, 2012
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):
SIGNATURE OF TANK OWNER:
DATE: 1h OWNER'S PHONE #: (661) 328 -0732
NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER
RESOURCES CONTROL BOARD). THE LOCAL AGENCY LIST IS AVAILABLE AT:
www. waterboards .ca.gov /ust /contacts/cuna agys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
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