HomeMy WebLinkAbout2700 OSWELL STREET (6)Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Oswell Chevron Facility ID #:
Facility Address: 2700 Oswell Street
Bakersfield, CA 93306
Reason for Submitting this Form (Check One)
0 Change ofDesignated Operator
lilt Update Certificate Expiration DateFacilityPhone #: (661) 871 -1200
Designated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Catherine Riccomini Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician 0 Third -Party
Business Name (Ifdifferentjrom above): Confidence USTServices, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8018933 -UC Expiration Date: October 8, 2010
ALTERNATE 1 (Optional)
Designated Operator's Name: Edward Mitchell Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician 0 Third -Party
Business Name (Ifdiifer•enijrom above): Conjdence USTServices, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 5258845 -UC Expiration Date: February 17, 2012
ALTERNATE 2 (Optional)
Designated Operator's Name: Douglas M Young III Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician & Third -Party
Business Name (Ifdifferentfi•an above): Confidence USTServices, Inc.
Designated Operator's Phone #: 800- 339 -9930
International Code Council Certification #: 0878646 -UC Expiration Date: September H, 2010
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): lye
SIGNATURE OF TANK OWNER:
DATE: U OWNER'S PHONE th 6(21- Z o I - / 5- ZZ
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: }_aicrhoards.ca.o ;ust /contacts /cuL a- gys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAY. S
OF THE CHANGE.
November 2004
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Oswell Chevron Facility ID #:
Facility Address: 2700 Oswell Street, Bakersfield, CA 93306
City)
Reason for Submitting this Form (Check One)
Change of Designated Operator
X Update Certificate Expiration DateFacilityPhone #: 661- 871 -1200
Desianated UST Operator(s) for this Facility
ALTERNATE 3 (Optional)
Designated Operator's Name: Sade C. Haake 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 #: 8080418 -UC Expiration Date: September 15, 2012
ALTERNATE 4 (Optional)
Designated Operator's Name: Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician Third -Party
Business Name (/fdierentfrown above):
Designated Operator's Phone #:
International Code Council Certification #: Expiration Date:
ALTERNATE
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 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): Reem Fahil
SIGNATURE OF TANK OWNER:
DATE: !p _/0 OWNER'S PHONE #: 661 - 201 -1522
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 acys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
p #
F 1 Fti
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VOUST
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COMPLIANCE WITH CONFIDENCE"
December 17, 2010
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 re Update Certificate Expiration Date for
Flower Street Mini Mart and Oswell Chevron.
Thank you for your attention herein.
Enclosures
CONFIDENCE UST SERVICES, INC.
Cheri Young, is -Pres dent
16250 Meacham Road • Bakersfield, CA 93314
661) 631 -3870 or (800) 339 -9930
FAX (661) 587 -9758