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HomeMy WebLinkAbout1140 MING AVENUE (2)11 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Grand Island Chevron (Sully's) Facility ID #: Facility Address: 1 140 Ming Avenue, Bakersfield, CA 93311 City of Bakersfield) Reason for Submitting this Form (Check One) 0 Change of Designated Operator Update Certificate Expiration DateFacilityPhone #: Desit?nated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Eric Santos Relation to UST Facility (Check One) Owner Operator Employee Service Technician 9 Third -Party Business Name (Ifdifferentfrom above): Confidence USTServices, Inc. Designated Operator's Phone #: 800- 339 -9930 International Code Council Certification #: 8135508 -UC Expiration Date: December 7, 2013 ALTERNATE l (Optional) Designated Operator's Name: Frank J. Landa 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 #: 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 Namc (1f(Ierentfrom above): Confidence UST Services, 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) - (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): Sullivan SIGNATURE OF TANK OWNER: DATE: I I OWNER'S PHONE #: 661 - 327 -5008 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 I Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Grand Island Chevron (Sully's) Facility ID #: Facility Address: 1 140 Ming Avenue, Bakersfield, CA 93311 City of Bakersfield) Reason for Submitting this Form (Check One) Nx Change of Designated Operator Update Certificate Expiration DateFacilityPhone #: 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 Nx Third -Party Business Name (lfdifferenlfrom 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 (00ional Designated Operator's Name: Kristopher Karns Relation to UST Facility (Check One) Owner Operator Employee Service Technician Z Third -Party Business Name (If (1i/Jerentfrom above): Confidence USTServices, 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 III Relation to UST Facility (Check One) Owner Operator Employee Service Technician Z Third -Party Business Name (Ifd4ferenlfrom above): Confidence UST Servicev, Inc. Designated Operator's Phone #: 800 - 339 -9930 International Code 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): _ Sullivan Petroleum Co., LLC SIGNATURE OF TANK OWNER: 1/ DATE: I,q1 \ OWNER'S PHONE #: 661- 327 -5008 r 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 /usUcontacts/cupa agys.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004