Laserfiche WebLink
t <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Valero Comer Store#3698 <br /> Facility ID#: FA0003709 <br /> Facility Address: I53 E. 11`"Street Reason for Submitting this Form(Check One) <br /> Tracy,CA 95376 <br /> ❑ Change of Designated Operator <br /> Facility Phone#:209-832-8815 <br /> ❑ Update Certificate this <br /> Dale <br /> Designated UST Oyerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Donald W.Marcetti <br /> Relation to UST Facility(Check One) <br /> Business Name(IJd�erentJrom above): Valero <br /> ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: 209-601-2373 <br /> ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8016976 <br /> Expiration Date:7/17/2014 <br /> ALTERNATE 1 Nona/ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name Ql'different from above:Valero <br /> ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: <br /> Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): Valero <br /> Designated ❑ O��' ❑ Operator X Employee <br /> gn Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: <br /> 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 California Code of <br /> Regulations, title 23, section 2715(c) <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 <br /> OR OWNERS AGENT (Please Print): Sandy Huff <br /> SIGNATURE OF TANK OWNER <br /> OR OWNERS AGENT: �Q( (Q 4"__ <br /> DATE: 71 Irl <br /> -T— OWNER'S PHONE#: 559-583-3298 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/list/contacts/coa a9vs html. <br /> November 2004 <br />