HomeMy WebLinkAbout3221 H STREET (4)BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK SYSTEM
OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND
UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS
For use by Unidoc.s Meniher Agencies or where approved h>> your Local Jurisdiclion
Authority Cited: Title 23, Div. 3, Ch. 16 California Code ofRegulations (CCR)
FACILITY NAME FACILITY PHONE
PAC BELL dba AT &T CALIFORNIA (SA098) 661) 327 -6903
FACILITY SITE ADDRESS CITY
3221 S. H Street Bakersfield
REASON FOR SUBMITTING THIS FORM (Check One): ® Change of Designated Operator Update of ICC Certification Expiration Date(s)
PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY
DESIGNATED OPERATOR NAME: Kirk Fowler RELATION TO UST FACILITY (Che(k One)
Owner Operator Employee
Service Technician ® Third -Party
1USINESS NAME (t /dilkrent %ram uhurel: Tait Environmental Services
DESIGNATED OPERATOR PHONE: (714) 920 -8201 ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: '5524370'55 -UC EXPIRATION DATE: 8/20/2012
ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional)
DESIGNATED OPERATOR NAME: See Attachment RELATION TO UST FACILITY (Check One)
Owner Operator Employee
Service Technician ® Third -Party
BUSINESS NAME (t /dij/erent /i-om ubove): Tait Environmental Services
DESIGNATED OPERATOR PHONE: ( ) ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: See Attachment EXPIRATION DATE: See Attachment
ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional)
DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY
Owner Operator
Service Technician
Check One)
Employee
El Third-Party
1USINESSNAME ( 1/ abmv):
DESIGNATED OPERATOR PHON1,-: ( ) ext.
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE:
ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional)
DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY
Owner Operator
Service Technician
Che(k One)
Employee
Third -Party
BUSINESS NAME (t /'di%/ereni./i-r,m (1h01'e):
DESIGNATED OPI'RATOR PHONE: ( ) ext
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE :
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) through (f). Furthermore, I understand and am
in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks.
TANK OWNER NAME: Steven J Hall
TANK OWNER TITLE:
Manager EH &S
TANK OWNER SIGNATURE:
INSTRUCTIONS
OWNER PHONE: 214 - 464 -3131
DATE: November 29, 2011
1. Report the name(s) ofthe Designated UST Operator(s) as registered with the International Code Council ([CC). ]CC certification information is available on -line at:
www .iccsafe.org /e /certsearch.himl. Search for "California UST System Operators."
2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact infornation are listed on -line
at: www.unidoes.org /members /whoregulateswhat.himl. Contact information for other local agencies within California is available at:
www.swrcb.ca.gov /cwphome /ust/ contacts /does /local_agency_lis(.xis.
3. 23 CCR j2715(a) requires that you notify the local agency ofany changes to this information within 30 days of the date of change.
UN -062 - 1/74 wwwmnidocs.org 09/22/05
ICC Certified Designated Operators
usiam ro zui cao«[aGa
Designated Operator Program Director: Paul McCarter — 714.560.8200
Name ICC Certification # Exp. Date Phone
Aguilar, Adolfo 5238610 -UC 02/08/2013 714.231.4393
Butler, Goldie 5245828 -UC 10/22/2012 714.920.7818
Brehmer, Scott 8013043 -UC 07/14/2012 714.720.2111
Dawson, Peter 5280692 -UC 01/13/2012 714.920.8238
Durham, Eric 5240929 -UC 11/22/2013 714.920.8239
Fowler, Kirk 5243705 -UC 08/20/2012 714.920.8201
Grylls, Gloria 8020100 -UC 10/09/2012 714.920.7970
Hall, Ian 5311539 -UC 03/02/2012 714.920.8215
Holbrook, Phil 5252931 -UC 09/15/2012 714.920.8236
Koffel, George 5247982 -UC 12/08/2012 714.920.5387
Larsen, Scott 8041113 -UC 08/16/2013 714.920.7661
Kostel, Timothy 5248172 -UC 07/28/2012 714.920.8214
McCarter, Paul 8067433 -UC 04/30/2012 714.719.6869
Riggins, Larry 5243198 -UC 09/22/2012 714.920.5477
Thruston, Yolanda 8020116 -UC 10/22/2012 714.920.7056
Last Updated 11/28/2011