HomeMy WebLinkAbout4013 H STREET (5)P
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Fastrip #22 (Exxon) Facility ID #: 3022
Facility Address: 4013 South —H- Street, Bakersfield, CA 93304
City)
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: 661 - 832 -6124
DesiEnated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Eric Santos Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician O Third -Party
Business Name (/fdfferentfrom above): Confidence USTServices, 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 0 Third -Party
Business Name (/fdifferentfrom 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 0 Third -Party
Business Name (fdifferentfrom above): Confidence USTServices, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8018933 -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): Jamieson Hill Co.
SIGNATURE OF TANK OWNER: v
C-0DATE: %/A // OWNER'S PHONE #: 661 - 393 -7000
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
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BSI - 7a I
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Fastrip #22 (Exxon) Facility ID #: 3022
Facility Address: 4013 South —H- Street, Bakersfield, CA 93304
City)
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: 661 -832 -6124
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 (Ifdr/%rent from above): Confidence USTServicesc, 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 Z Third -Party
Business Name (/fdiifBrentfrom above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Cale Council Certification #: 5264406 -UC Expiration Date: July 19, 2013
ALTERNATE 5 (Optional)
Designated Operator's Name: Douglas M. Young 111 Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (Ifdi/%rentfrom above): Confidence UST Seances, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Cale Council Certification #: 8043499 -UC Expiration Date: September 12, 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): Jamieson Hill Co.
SIGNATURE OF TANK OWNER: Please see page one
DATE: OWNER'S PHONE #: 661 - 393 -7000
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/cupaa agys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004