HomeMy WebLinkAbout4901 UNION AVENUE (6)pr
7-751-725
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Fastrip #19 (Exxon) Facility ID #: 3076
Facility Address: 4901 So. Union Avenue, Bakersfield, CA 93307
City)
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: 661- 397 -9387
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 (Ifdifferentfrom above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8018933 -UC Expiration Date: September 8, 2012
ALTERNATE 1 (Optional)
Designated Operator's Name: Frank Landa 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 #: 8018524 -UC Expiration Date: July 12, 2013
ALTERNATE 2 (Optional)
Designated Operator's Name: Sade C. Haake Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (Ifdifferentfrom above): Confidence USTServices, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8080418 -UC Expiration Date: September 15, 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) - (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 Jamieson Hill Co.
SIGNATURE OF TANK OWNER. e5
DATE: 8/12/2011 v` OWNER'S PHONE #: 661 - 393 -7000
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 /cuna ag sue.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
V,
x'75 / 72S
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Fastrip #19 (Exxon) Facility ID #: 3076
Facility Address: 4901 So. Union Avenue, Bakersfield, CA 93307
City)
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: 661 - 397 -9387
Designated UST Operator(s) for this Facility
ALTERNATE 3 (Optional)
Designated Operator's Name: Edward Mitchell Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (!fdfferentfrom above): Confidence UST Services, Inc. IDesignatedOperator's Phone #: 800- 339 -9930
International Code Council Certification #: 5258845 -UC Expiration Date: February 17, 2012
ALTERNATE 4 (Optional)
Designated Operator's Name: Bryan A Self Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (!fdifferentfrom above): Confirdence UST Services, inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8022804 -UC Expiration Date: November 19, 2012
ALTERNATE 5 (Optional)
Designated Operator's Name: Kristopher M. Karns Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (/fdifferentfrom above):. Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 5264406 -UC Expiration Date: July 19, 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
DATE: 8/12/2011 OWNER'S PRONE #: 661 - 393 -7000
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 /cupa agys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
r
7 - 751 -7:2 5
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Fastrip #19 (Exxon) Facility ID #: 3076
Facility Address: 4901 So. Union Avenue, Bakersfield, CA 93307
City)
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: 661- 397 -9387
Designated UST Operator(s) for this Facility
ALTERNATE 6 (Optional)
Designated Operator's Name: Douglas M. Young Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (/fdifferentfrom above): Confidence USTServices, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 0878646 -UC Expiration Date: September 8, 2012
ALTERNATE 7 (Optional)
Designated Operator's Name: Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician Third -Party
Business Name Qrdifferentfrom above):
Designated Operator's Phone #:
International Code Council Certification #: Expiration Date:
ALTERNATE 8 (Optional)
Designated Operator's Name: Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician Third -Party
Business Name (/fdifferentfrom above):.
Designated Operator's Phone #:
International Code Council Certification #: 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) - (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): Jamieson Hill G
SIGNATURE OF TANK
DATE: 8/12/2011 v" OWNER'S PHONE #: 661- 393 -7000
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 /cupa agys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004