HomeMy WebLinkAbout3300 WHITE LANE (3)Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: SamCo Food Store #2 Facility ID #: FA0026858
Facility Address: 3300 White Lane, Bakersfield, CA 93309
City)
Reason for Submitting this Form (Check One)
x Change of Designated Operator
X Update Certificate Expiration DateFacilityPhone #: 661- 827 -0487
Designated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Catherine C. Riccomini Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (Ifdifferent from above): Confidence UST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8018933 -UC Expiration Date: August 30, 2014
ALTERNATE 1 (Optional)
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 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: Eric R. Santos Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician x Third -Party
Business Name (Ifdifferentfrom above): Confidence LIST Services, Inc.
Designated Operator's Phone #: 800 - 339 -9930
International Code Council Certification #: 8015508 -UC Expiration Date: December 7, 2013
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): Sharon K. Trent, Retail Rep.,Sullivan Petrol.
SIGNATURE OF +TANNK OWNER:
A
DATE: — l 11_`' k, 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 aays.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
11 . .
s
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: SamCo Food Store #2 Facility ID #: FA0026858
Facility Address: 3300 White Lane, Bakersfield, CA 93309
City)
Reason for Submitting this Form (Check One)
x Change of Designated Operator
Update Certificate Expiration DateFacilityPhone #: 661- 827 -0487
Designated UST Operator(s) for this Facility
ALTERNATE 3 (Optional)
Designated Operator's Name: Bryan A. Self 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 #: 8022804 -UC Expiration Date: November 19, 2012
ALTERNATE 4 (Optional)
Designated Operator's Name: Kristopher M. Kerns 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: Sandra Witcher 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 #: 8169591 -UC Expiration Date: August 15, 2014
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
SIGNATURE OF TANK OWNER:
DATE: qj 1(411.), Cj
Sharon K. Trent, Retail Rep.,Sullivan Petrol.
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.j4ov/ust/contacts/cupa agys.htm1.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
ti
OP 4.
9hCE5 v
COMPLIANCE WITH CONFIDENCE"
December 9, 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 Samco
Food Store #2.
Thank you for your attention herein.
Enclosure
CONFIDENCE UST SERVICES, INC.
Cheri Yo `g Vice -P sident
16250 Meacham Road • Bakersfield, CA 93314
661) 631 -3870 or (800) 339 -9930
FAX (661) 587 -9758