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HomeMy WebLinkAbout4600 STINE ROAD (5)09 -20- 11;15:28 ; 8310716 # 1/ 2 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Namcx MNM Station Facility Addtuss: 4600 Stine Road Bakersfield, CA 93309 Facility ID 1l: Reason for Submitting this Fonn (Check One) Change ofDmignated Operator Update Certificate Expiration DateFacilityPhone0: Desitenated UST Onerator(s) for this Facility Designated Operator's Name: Frank Landa Business Name (fdr,;'erentfrom above): Cnnfrdeme UST .Servlcee. Inc. Designated Operator's Phone #: 800 - 339 -9930 International Coderouncil Certification #: R018524 -UC AL'1'LK NA"lEi t (UpnonaQ Designated Operator's Name: Catherine Riccomini Busincw Name (Ifdtffe wfrum above): Confidence USTServices. Inc. Ocaignated Operator's Phone #: 800. 339 -9930 International Code Council C<atificatinn }l: 8018933 -UC AL'rERNATrs 2 (Optional) Designated Operator's Name: Edward Mitchell Business Namc (Ifilierent jrorn above): Confidence USTServ4ve9. Inc. Designated Operator's Phone #: 800 - 339 -9930 International Code Council CAztification #: 5258845 -UC Relation to UST Facility (Check One) Owner Operator Employee Service Technician ® Third - Party Expiration Date: July 12, 2013 Relation to UST Facility (Check One) owner rl Operator Employee Service Techniciau 9 Third -Party Expiration Date: September 8, 2012 Relation to UST Facility (Check One) U Owncr Operator Employes Sctviee Technician 9 T 6rcl -Party Expiration I?ate: February 17. 2012 1 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 told document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, l understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please Print): (,/ - L SIGNATURE OF TANK OWNER, Sj {.! 01 - 05 DATE: L22 OWNER'S PRONE # NOTE: 1) SUBMFF THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STAY'E WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE, AT: vvww.waterbctards.ca.gov/us;t/wntacts/cupa_agvs.httnl- 2) NOTIFY THE FOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION W11•HIN 30 DAYS pF T14E CHANCE. Novcmbcr 2004 09 -20- 11;15:23 ; 8310716 ; # 2/ 2 Owner Statements of Designated Underground Storage Tank. (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Metro Station Facility Ill #: Facility Address: 4600 Stinc !toad Reason for Submitting this Fonn ((;heck One) Bakersfield, CA 93309 DD Change ofDesignated Operntur Facility Phone #: n Update Certificate Expiration Date Desitrrtated UST Operator(s) for this Facility Designated Operatnr'F Namc: Bryan Self Business, Name (if &Confidence) /ST.Sendcrj, Inc. Designated Operator's Phone ii: 800 -339 -99341 Internaticoal Code Council Certitmtion #: 802290441C ALTERNATE t ([)unman Relation to UST Facility (Check One) Owner Operator Employee Service Techni6an © Third -Party Expiration Date: November 19, 2012 Designated Uperator's Name: Kristopher Karns Relation to UST Facility (Check One) Business Name (jdifferentfrom above)_ Confidence UXT Services, Inc. Owner OperpWr Employee Service Technician 19 Third -PartyDcsigtiatcdOperator's Phone #: 800 -339 -9930 International C'.ode Council Certification #: 5264406 -UC Expiration Date! July 18, 2013 AL I LKIYA I L I (Uptionat) Designated Operator's Name: Relation to UST Facility (Check One) Business Name (!fdifferentfrom above): Confidence USI'Ser4ca, Inc, Owner Operatur P.mployec Dcsignatcd Operator's Phone #: 800-339 -9930 Service 'technician Third -Harty International Code Council Certification it: Expiration Date: I certify that, fiat the facility indicated at the top ofthis page, the individual(s) fisted 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 Cade 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): S G SIGNATURE OF TANK OWNER: j l g A DATE: 9-6 ' OWNER'S PHONE #: SYs "G NOTE;: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE S'rATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE, AT: www. watcrboards.ca.gov /ust/contacts/Cupa ajzwhtxl. 2) NOT1[FY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WrrliJ(N 30 DAYS OF THE CHANGE. November 2004 OAF I DFti V N . 0hCES 4 COMPLIANCE WITH CONFIDENCE" September 22, 2011 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 Metro Station. Thank you for your attention herein. Enclosure Yours truly, CONFIDENCE UST SERVICES, INC. Karli Karns, Dispatch Coordinator 16250 Meacham Road • Bakersfield, CA 93314 661) 631 -3870 or (800) 339 -9930 FAX (661) 587 -9758