COMPLIANCE INFO 2008-2012 - Laserfiche WebLink

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t Owner Statemenf Designated Underground Stor� Tank (UST) Operator and Understate, ling of and Compliance with US .equirements Facility Name: 7-1114117 Facility ID: 14117 Facility Address: 2725 COUNTRY CLUB BLVD Reason for Submitting this Form(Check One) STOCKTON,CA 95204 ■ Change of Designated Operator Facility Phone#: (209)463-1259 ❑ Updated Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY _ Designated Operator's Name: Brian Hernandez Relation to the UST Facility(Check One) Business Name(If different from above): Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ■ Third-Party International Code Council Certification#: 5308636-UC Expiration Date: 4/612009 ALTERNATE1 Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operators Phone#: refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification#: refer to backup document Expiration Date: refer to backup document g erators Name: refer to backup document Relation to the UST Facility(Check One) e(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee erators Phone M refer to backup document ❑ Service Technician ■ Third-Party ode Council Certification#: refer to backup document Expiration Date: refer to backup document Fthat, for the facility indicated at the top of this page, the individual(s) listed above will s Designated UST Operator(s). The individual(s) will conduct and document monthlynspections and annual facility employee training, in accordance with California Codeof tions, title 23, section 2715(c) - (f). Futhermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): n dOo r 41 co Signature of Tank Owner: Date: 0" 9 0 P Owner's Phone #: q//„ — 3— �i ,% 7 RES URCES JIANUARY1,SUBMIT005.THE LOCAL AGENCYL ST ISAVAILABLEAT:www.watterboa ds.ca.govHE LOCAL AGENCY(NOT THE STATE/usVeoATEntacts/c0 pa_agys.htCONTROL BOARD)BY mi. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.