HomeMy WebLinkAbout3300 WHITE LANE (4)Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: SamCo Food Store 92 Facility ID #:
Facility Address: 3300 White Lane, Bakersfield, CA 93309
City)
Reason for Submitting this Form (Check One)
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 (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 1 (Optional)
Designated Operator's Name: Edward Mitchell Relation to UST Facility (Check One)
Owner Operator Employee
Service Technician X Third -Party
Business Name (Ifdifferentfrom above): Confdente UST Services, 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 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 #: 0878646 -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) - (fl.
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): 4'Tre_;1;
5u th'V4 f1
SIGNATURE OF TANK OWNER:_ ," /
DATE: D OWNER'S PHONE #: t-///— 3.P -7- ;S'Oa r'
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 al;ys.html.
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
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 #:
Facility Address: 3300 White Lane, Bakersfield, CA 93309
City)
Reason for Submitting this Form (Check One)
Change of Designated Operator
X Update Certificate Expiration DateFacilityPhone #: 661- 827 -0487
Designated 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 (Ifdifferent from above): Confidence UST Services, 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 (Ifdifferentfrom 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 (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): -4 v r-
K _77, v
SIGNATURE OF TANK OWNER: TL
DATE: 6 /D( OWNER'S PHONE #: ;2 Sid
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.
November 2004
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