HomeMy WebLinkAbout6009 COFFEE RD (3) ' I IIIIIiI VIII III IIII 65
IE
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Big Country Z4x3Co Chev ro,\ Facility ID#:
Facility Address: 6009 Coffee Road,Bakersfield,CA 93308 Reason for Submitting this Form(Check One)
(City) ❑ Change of Designated Operator
Facility Phone#: X Update Certificate Expiration Date
Designated UST Operators) for this Facility
PRIMARY
Designated Operator's Name: Catherine C. Riccomini Relation to UST Facility(Check One)
Business Name(Ifdifferentfrom above): Confidence USTServices,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 1(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(If dierentfromabove):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): Li��t _ullivan
SIGNATURE OF TANK OWNER:
DATE: //�/ /(O OWNER'S PHONE#: 661-327-5008
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 a yg_s.html.
2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
IIIIIIIIIIIIIIIIIIII November 2004
66
IE
Owner Statements of Designated Underground Storage Tank (UST) Operator
t4 and Understanding of and Compliance with UST Requirements
Facility Name: Big Country T.o*nn C�GUra Facility ID#:
Facility Address: 6009 Coffee Road, Bakersfield,CA 93308 Reason for Submitting this Form(Check One)
(City) ❑ Change of Designated Operator
Facility Phone#: X Update Certificate Expiration Date
Desianated 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 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#: 8080418-UC Expiration Date: September 15,2012
ALTERNATE 4(Optional)
Designated Operator's Name: Relation to UST Facility(Check One)
Business Name(f different from above): ❑ Owner ❑ Operator ❑ Employee
Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party
International Code Council Certification#: Expiration Date:
ALTERNATE
Designated Operator's Name: Relation to UST Facility(Check One)
(^ Business Name(If different 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) - (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): K S,_,_1yU",h
SIGNATURE OF TANK OWNER: _
DATE: �`!�/�<7 OWNER'S PHONE#: 66?—_D_7_E()0a
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.i,ov/ust/contacts/cupa a ws1, htnil.
i
2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004