HomeMy WebLinkAboutUST Statement of D.O. Compliance 2010 r 111111 61
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Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Proactive Properties,Inc.dba White Lane Chevron Facility ID#:
Facility Address: 2525 White Lane,Bakersfield,CA 93304 Reason for Submitting this Form(Check One)
(City) to Change of Designated Operator
Facility Phone#: 661-832-9781 X Update Certificate Expiration Date
Designated UST Operator(s) for this Facility
PRIMARY
Designated Operator's Name: Catherine C.Riccomini Relation to UST Facility(Check One)
Business Name(If different from above): Confidence UST Services, Inc. ❑ Owner ❑ Operator ❑ Employee
Designated Operator's Phone#: 800-339-9930 ❑ Service Technician X Third-Party
International Code Council Certification#: 8018933-UC Expiration Date: September 8, 2012
ALTERNATE l (Optional)
Designated Operator's Name: Edward Mitchell Relation to UST Facility(Check One)
Business Name(If different from above): Confidence UST Services, Inc. ❑ Owner ❑ Operator ❑ Employee
Designated Operator's Phone#: 800-339-9930 ❑ Service Technician X Third-Party
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)
Business Name(Ifdifferent from above):Confidence UST Services, Inc. ❑ Owner ❑ Operator ❑ Employee
Designated Operator's Phone#: 800-339-9930 ❑ Service Technician x Third-Party
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) - (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): n Gaby Jabbour
SIGNATURE OF TANK OWNER:
Nu
DATE: R/Zo� ° OWNER'S PHONE#: 805-444-4229
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.
62
1111 IIIII111 November 2004
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Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Chevron Facility ID#:
Facility Address: 2525 White Lane Reason for Submitting this Form(Check One)
Bakersfield,CA 93304 ❑ Change of Designated Operator
Facility Phone#: X Update Certificate Expiration Date
Designated UST Operator(s) for this Facility
ALTERNATE 3(Optional)
Designated Operator's Name: Sade C.Haake Relation to UST Facility(Check One)
Business Name(If dierent from above):Confidence UST Services, Inc. ❑ Owner ❑ Operator ❑ Employee
Designated Operator's Phone#: 800-339-9930 ❑ Service Technician X Third-Party
International Code Council Certification#: 8080418-UC Expiration Date: September 15,2012
ALTERNATE 4(Optional)
Designated Operator's Name: Relation to UST Facility(Check One)
Business Name(If different from above): ❑ Owner O Operator ❑ Employee
Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party
Intemational Code Council Certification#: Expiration Date:
ALTERNATE
Designated Operator's Name: Relation to UST Facility(Check One)
Business Name(ff dierenl from above):. ❑ Owner ❑ Operator ❑ Employee
Designated Operator's Phone#: ❑ Service Technician Third-Party
International Code Council Certification#: 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) - (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):
SIGNATURE OF TANK OWNER: See Page 1
DATE: OWNER'S PHONE#:
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: »,w%v.waterbcktrd s.ca.gov/usUcotttacts/cups agys.htntl.
2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004
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"COMPLIANCE WITH CONFIDENCE"
October 11, 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
Chevron.
Thank you for your attention herein.
CONFIDENCE UST SERVICES, INC.
LCh�efri Youn , Vice-President
Enclosure
16250 Meacham Road • Bakersfield, CA 93314
(661) 631-3870 or (800) 339-9930
FAX (661) 587-9758