HomeMy WebLinkAbout8010 KERN CANYON ROADOwner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: 5 Star Gas Shell Facility ID #:
Facility Address: 8010 Kern Canyon Road, Bakersfield, CA 93306
City)
Reason for Submitting this Form (Check One)
X Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: 661- 366 -7116
Designated UST Operator(s) for this Facility
ALTERNATE 3 (Optional)
Designated Operator's Name: Bryan Self Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (Ifdifferent from above): Confidence UST Services. 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 Karns Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (Ifdifferentfrom above): Confidence UST Services, 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: Sandra Witcher Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (Ifdierentfrom above): Confidence USTServices, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8019591 -UC Expiration Date: August 15, 2014
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) - (fl.
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): K A71 L-4 r T D h / L Le> 1V
SIGNATURE OF TANK OWNER: (Please see page one) )Z-- ; /,1"
f °`'
DATE: I oP-& l Z- OWNER'S PHONE #:
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/cupa agys.html.
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: 5 Star Gas Shell Facility ID #:
Facility Address: 8010 Kern Canyon Road, Bakersfield, CA 93306
City)
Reason for Submitting this Form (Check One)
X Change of Designated Operator
X Update Certificate Expiration DateFacilityPhone #: 661- 366 -7116
Designated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Eric Santos Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician OO Third -Party
Business Name (Ifdifferentfrom above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8135508 -UC Expiration Date: December 7, 2013
ALTERNATE 1 (Optional)
Designated Operator's Name: Frank J. Landa Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (fdrljerentfrom above): Confidence USTServices. 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: Catherine Riccomini Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician F] Third -Party
Business Name (Ifdifferentfrom above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8018933 -UC Expiration Date: August 30, 2014
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) - (0.
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): lX A P1 A l—/ /`f Dn I L- Lo Iy
SIGNATURE OF TANK OWNER: 1 't i) tl IIa
DATE: OWNER'S PHONE
l
AX
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/contact-,/cuia at;ys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
p#* DFti
V C
N .
0hCES V?
COMPLIANCE WITH CONFIDENCE"
October 30, 2012
CITY OF BAKERSFIELD
Fire Prevention Services
2101 -H- Street
Bakersfield, CA 93301
To Whom It May Concern:
Enclosed please find completed Owner Statements of
Designated UST Operator and Understanding of and Compliance with
UST Requirements for 5 Star Gas Shell, 4010 Arco AM /PM, Big
Country Chevron, Downtown Chevron, Grand Island Chevron
Sully's), Mt. Vernon & Columbus Arco AM PM, Olive Drive
Chevron, Oswell Chevron and SamCo Food Store #2.
Please feel free to contact Catherine Riccomini of our
office should you have any questions or concerns. Thank you.
Enclosure
CONFIDENCE UST SERVICES, INC.
Cheri Yo .ice -P sldent
16250 Meacham Road • Bakersfield, CA 93314
661) 631 -3870 or (800) 339 -9930
FAX (661) 587 -9758