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I <br /> } <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements i <br /> Facility Names COSTGO 1031 ; Facility ID: 1031 <br /> Facility Address: 2440 DANIELS ST. Reason for Submitting this Form(Check One) <br /> lVr4NTEGA,CA 95338 L2 Change of Designated Operator i <br /> Facility Phone# 2098258200 — - I a Updated Certificate Expiration Date <br /> i <br /> Designated UST Operator(s)fnr this Facilites <br /> I <br /> PRIMARY <br /> I3esignated Operator's Name: Brian Hemandez _— ! Relation to the UST Facility(Check flue) <br /> Business Warne(If different`ram above): Selshire Environmental Services,rnc7 ❑ Owner o Operator ❑ Employee <br /> Designated Operator's Phone#: (949)480.5200 ' ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#. 5308638••t1C - -_ ~ Expiration Date: W7120111 <br /> ALTERNATEI <br /> Designated Operator's Name: refer to backup document _ Relation to the UST Facility(Check One) <br /> Business Name(If different from above): refer to backup document i ❑ Owner Ia Operator n E=mployee <br /> Designated Operator's Phone#: refer to backup document` _.T� ❑ Service Technician >• T niw-party i <br /> International Code Council Certification* refer to backup document iration Date: refer to backup document <br /> ALTERNATE 2 <br /> Designated Operat4i's Name: refer to backup document 1 Relation to the UST Facility(CheckQne) ? <br /> Business Name(if different from above): refer to backup docuwnt ❑ Owner ❑ Operator ❑ Employee <br /> �slgnated Operator s Phon9#: rpf®r fo backup dacurnent ❑ 59nrice TPchnic7anrl nitrParty <br /> emational Code Council Certification#: refer to backup document Expiration Dale: refer to backup dceument <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 California Code*of <br /> Regulations, title 23, section 2715(c)- (f) <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances) applicable to underground Storage tanks <br /> Name of Tank Owner(print): _ N is <br /> I <br /> Signature of Tank owner-- <br /> Date: <br /> wner:Date: f/ �1 Owner's phone * <br /> NOTE:t)SUBMIT THIS COMPLETED FORM TO T iE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY I <br /> JANUARY 1,2005 THE LOCAL AGENCY LIST IS AVAILABLE AT:www waterboards ca govlusticontactslcupa_agys html <br /> 2)NOTIFY TI=E LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 311 DAYS OF fHE CHANGE <br /> t <br />