HomeMy WebLinkAbout2101 H STREETOwner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Chevron Facility ID #:
Facility Address: NWC Ming Ave. & Buena Vista Rd.
Bakersfield, CA 93311
Reason for Submitting this Form (Check
Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #:
Designated UST Operator(s) for this Facility
PRIMARY
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 #: 8015124 -UC Expiration Date: July 12, 2013
ALTERNATE 1 (Optional)
Designated Operator's Name: Catherine 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 2 (Optional)
Designated Operator's Name: Edward Mitchell Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (If differentfrom above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 5258845 -UC Expiration Date: February 17, 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): 1 _R l'pk
SIGNATURE OF TANK OWNER: --4-
v
DATE: ( OWNER'S PHONE #: 661 - 393 -7000
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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.
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Chevron Facility ID #:
Facility Address: NWC Ming Ave. & Buena Vista Rd.
Bakersfield, CA 93311
Reason for Submitting this Form (Check
Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #:
Desiiinated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Bryan Self Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician Z Third -Party
Business Name (Ifdifferentfrom above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8022804 -UC Expiration Date: November 18, 2012
ALTERNATE 1 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 18, 2013
ALTERNATE 2 (Optional)
Designated Operator's Name: Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician Third -Party
Business Name (Ifdifferentfrom above):
Designated Operator's Phone #:
International Code Council Certification #: Expiration Date:
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 OWNER:
DATE: I R'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 /cupaa agys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30
DAYS OF THE CHANGE.
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C. A141'.1c
COMPLIANCE WITH CONFIDENCE"
November 15, 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 Chevron.
Thank you for your attention herein.
Enclosure
Yours truly,
CONFIDENCE UST SERVICES, INC.
e6GIC (-- A "---/
Karli Karns, Dispatch Coordinator
16250 Meacham Road • Bakersfield, CA 93314
661) 631 -3870 or (800) 339 -9930
FAX (661) 587 -9758