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BAKERSFIELD FIRE DEPARTMENT
UNDERGROUND STORAGE TANK SYSTEM
OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND
UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS
For use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR)
FACILITY NAME FACILITY PHONE
AT&T CORP (CAK010) (559) 228-7056
FACILITY SITE ADDRESS CITY
1520 20th St. Bakersfield
REASON FOR SUBMITTING THIS FORM(Check One): E Change of Designated Operator 0 Update of ICC Certification Expiration Date(s)
PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY
DESIGNATED OPERATOR NAME: TORT ROSS RELATION TO UST FACILITY(Check One)
BUSINESS NAME(tfdifferenifi•omabove): CALIFORNIA HAZARDOUS SERVICES, INC. ❑ Owner ❑ Operator ❑ Employee
DESIGNATED OPERATOR PHONE: (714) 719_0721 ext. ❑ Service Technician ® Third-Party
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5262038-UC EXPIRATION DATE: 10/15/2012
ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional)
DESIGNATED OPERATOR NAME: Brian Halfwassen RELATION TO UST FACILITY(Check One)
BUSINESS NAME(Ifdifferenrfromabove): CALIFORNIA HAZARDOUS SERVICES, INC. ❑ Owner ❑ Operator ❑ Employee
DESIGNATED OPERATOR PHONE: (714)434-9995 ext. ❑ Service Technician ® Third-Party
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 55006847-UC EXPIRATION DATE: 09/01/2012
ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional)
DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One)
BUSINESS NAME Qf di ferent ftom above): ❑ Owner ❑ Operator ❑ Employee
DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE:
ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional)
DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One)
BUSINESS NAME(If different from above): ❑ Owner ❑ Operator ❑ Employee
DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party
INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE:
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) through (f). Furthermore, 1 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 OWNER PHONE: 214-464-3131
TANK OWNER SIGNATURE: DATE: April 26, 2011
INSTRUCTIONS
1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC).ICC certification information is available on-line at:
www.icesafe.org/c/certsearch.htmi.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 information are listed on-line
at: www.unidoes.org/members/whoregulateswhat.htmi. Contact information for other local agencies within ,California is available at:
www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_l istxis.
3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change.
UN-062-1/1 www.unidocs.org I IIII�I VIII III/III 76 09/22/05
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April 26, 2011
UST Compliance Department
Bakersfield Fire Department
1501 Truxtun Ave
Bakersfield, CA 93301
RE: Letter of Transmittal
FedEx 7970-3052-4922
To whom it may concern,
Enclosed please find copy(ies) of:
Owners Statements) for the following location(s):
CAK010 - 1520 20th St, Bakersfield
Please return applicable approval pages to:
Steven ] Hall
C/O AT&T EH&S
308 South Akard St. Room 1700
Dallas, TX 75202
If you have any questions or require any additional information, please feel
free to contact me at (214) 464.3131 or by email at sh1975 @att.com.
Thank you for your help complying with this requirement.
Sincerely,
Steven 7 Hall
Manager, Environment, Health & Safety
AT&T Services Inc.
CC: AT&T EH&S National Tank File Retention
Pmutl SPonwr of the U.S.Olympic Team