HomeMy WebLinkAbout8001 WHITE LN (6) 1111111111 01 3b(,P,-7
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Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Fastrip#640(Chevron) Facility ID#: 3523/3725
Facility Address: 8001 White Lane,Bakersfield,CA 93309 Reason for Submitting this Form(Check One)
(City) ❑ Change of Designated Operator
Facility Phone#: 661-835-1490 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 dif'erent 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 1 (Optional)
Designated Operator's Name: Edward Mitchell 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#: 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 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#: 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): Jaco Hill Co.
SIGNATURE OF TANK OWNER: C]
DATE: September 8, 2010 OWNER'S PHONE#: 661-393-7000
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.
IIIIIIIIIIIIIIIIIIII November 2004
02
IE
Owner Statements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility Name: Fastrip#640(Chevron) Facility ID#: 3523/3725
Facility Address: 8001 White Lane,Bakersfield,CA 93309 Reason for Submitting this Form(Check One)
(City) ❑ Change of Designated Operator
Facility Phone#: 661-835-1490 X Update Certificate Expiration Date
Desig=nated UST Overator(s) for this Facility
ALTERNATE 3 O tiona
Designated Operator's Name: Sade C.Haake Relation to UST Facility(Check One)
Business Name(If dierentfrom 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 d fferent 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) - (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): Jaco Hill Co.
SIGNATURE OF TANK OWNER: See page 1
DATE: September 15 2010 OWNER'S PHONE#: 661-393-7000
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