Laserfiche WebLink
/y? � <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> " and Understanding of and Compliance with UST Requirements <br /> Facility Name:A One Gas&Food racility ID#: <br /> Facility Address:574 W.Grtmtlinc Reason for Submitting this Form(Check One) <br /> Tracy,CA_95376 ❑ Change of Designated Operator <br /> Facility Phone;;:(toy)883-3416 X Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Rclailon to UST facility(Check Une) <br /> Business Name(If dii ferent from above): ❑ Owner d Operator ❑ Employee <br /> Designated operator's Phuuc ow:(209)518-4836 L Service l echnician X Third-Party <br /> International Code Council Cenitication#:5266643-UC Expiration Date:07/16/09 <br /> ALTERNATE 1 O Uunut <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> 13usiness Name(/f dif crcn1 fes,n above): Cl Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician C] Third-Parry <br /> International Code Council Cc,tificntioll4; Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name; Relation to UST Facility(Check One) <br /> Business Name(Ifdlj)renrfrom above), Q Owner Q Operator O Employee <br /> Designated Operator's Pholic ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> I certify that, for the facility indicated at the top of this page, the individual(S)listed above will <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with Califon-iia Code of <br /> Regulations,title 23, section 2715(c)-(f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): aq�sb <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 08/22/07 OWNER'$PHONE#; C'✓ --� ?j?j- -- .4 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)RY;IANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.pov_/usUcontacts/cuy# aas.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> Z0/Z0 39hd Q❑❑.J Sh9 310 h 9L9L£C260' 0b L0 L006 ( (, 0 <br />