Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> �i and Understanding of and Compliance With UST Requirements <br /> Facility Name: Facility ID#: <br /> Fatality Address: I a V ". W 9 Reason for Suhm this Foran(Chick Ona) <br /> X Change of Designated Opmw <br /> Faerlity Phone# '. Update Certificate Expiration Date <br /> Desisnated UST Operator(s)for this Facility <br /> PRIMARY <br /> DOsigo� opciami-s Name:Karen R Arnam Relation to UST Facility(Check Che) <br /> Business Name(ifdyferenr from above): ❑ owner i] opemw ❑ Employee <br /> Desigomd operavies Phone#:(209) 518-4836 ❑ Service Technician X Third-Party <br /> Iniemationai Code Council Ce Asuon#:8032295-UC Expiration Daae:06/20/2011 <br /> ALTERNATE <br /> Desigosted Operator's Name: Relation to UST Facility(Check One) <br /> Rosiness Name(Ifdf$erentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ service Technician ❑ Third-Party <br /> #international Code Cotmol Certification C Expimtion Date: <br /> ALTERNATE 2 (OptiahldJ <br /> Designated Operator's Name: Relation to UFT Facility(Check One) <br /> Busmcs�Name(ifdiffemw from above): ❑ owner Q operator ❑ Employee <br /> Designated operator's Phone#: ❑ Semoe Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Data <br /> 1 certify that, for the facility irniicated 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 California Code of <br /> Regulations,title 23, section 2715(c)-(f). <br /> Furthermore,)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): `C—T2✓9£ fl <br /> SIGNATURE OF TANK OWNER <br /> DATE:�_OWNER'S PHONE#: LIOS 1 CJ t F O \ <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO TIIE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2003.THE LOCAL AGENCY LIST IS AVAH.ABLE <br /> AT.Aww.waterboards.caso_viasycontacts!cupa ar vs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CaANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> b00/800 d 9000# aoetd}amaeH R.ijunoo 9ZZZL6660ZL 80 11 OLOZ/60/b0 <br />