COMPLIANCE INFO 2004-2009 - Laserfiche WebLink

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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements FacilityName: c i2-p cuvn 7L rz„^= Facility ID#: Facility Address: Reason for Submitting this Form(Check One) U IVK.- v \Q r, ❑ Change of Designated Operator Facility Phone#: "zp� t-1 , O Update Certificate Expiration Date Designated UST ODerator(s)for this Facility PRIMARY Designated Operator's Name: Relation to UST Facility(Check One) Business Name([fdifferenrfrom above):P ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:(iZt> -01160 . ❑ Service Technician Third-Party Intemational.Code Council Certification#: . 7,47-6 t0 p Expiration Date: _ ALTERNATE nal Desi is Name: Relation to UST Facility(Check One) Business Name Qfdlfferentfrom ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: ALTERNAT Designated Operator's Name: Relation to UST Facility(Check One) Business Name pfdifferent from above): - ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: 'ration Date: NOTE.THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF-XNY CHANGES TO THIS INFORMATION WITHIN 30,,DAYS OF THE CHANGE. - 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 ih compliance with the requirements(statutes, regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER OR OWNER'S AGENT(Please Print): K \^R R I _ I S I f/V G fl SIGNATURE OF TANK OW OWNERER OR OWNER'S AGENT: DATE: 1 0�4 ' OWNER'S PHONE#: