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HomeMy WebLinkAbout2732 BRUNDAGE LANE (6)I?- 33 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: D and G Facility ID #: 2916 Facility Address: 2732 Brundage Lane, Bakersfield, CA 93304 City) Reason for Submitting this Form (Check One) x Change of Designated Operator Update Certificate Expiration DateFacilityPhone #: 661- 323 -5444 Desip_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 0 Third -Party Business Name (Ifdifferentfrom above): Confidence UST Services, 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 x Third -Party Business Name (Ifdifferentfrom above): Confidence USTSenncav, 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 Z Third -Party Business Name (Ifdiferenlfrom 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) - (0. 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): Jaco SIGNATURE OF TANK OWNER: DATE: /' Ila/ J 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 c2 33 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: D and G Facility ID #: 2916 Facility Address: 2732 Brundage Lane, Bakersfield, CA 93304 City) Reason for Submitting this Form (Check One) x Change of Designated Operator Update Certificate Expiration DateFacilityPhone #: 661- 323 -5444 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 O 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 19, 2012 ALTERNATE 4 (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 19, 2013 ALTERNATE 5 (Optional) Designated Operator's Name: Douglas M. Young III 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 #: 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): Jaco 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/cupa agys.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004 v 010 a N , FthcES `e COMPLIANCE WITH CONFIDENCE" CITY OF BAKERSFIELD Fire Prevention Services 2101 -H- Street Bakersfield, CA 93301 To Whom It May Concern: Enclosed please find completed Owner Designated UST Operator and Understanding UST Requirements re Change of Designated Country Chevron, Downtown Chevron, Flower Grand Island Chevron, Olive Drive Chevron 2. January 23, 2012 Statements of of and Compliance with Operator for Big Street Mini Mart, and Samco Food Store Please feel free to contact me should you have any questions. Thank you. Enclosures CONFIDENCE UST SERVICES, INC. GWw Cheri Young V'ce -Pr ident 16250 Meacham Road • Bakersfield, CA 93314 661) 631 -3870 or (800) 339 -9930 FAX (661) 587 -9758