Laserfiche WebLink
t'tEC 2 9 2004 <br /> ENVIRONNliN I HDILTH <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Fnaillry vo,*a IlfornaA taAS strvfroAt L•�•G� q( F4614ylD t, <br /> �'� w W r �7rrAlV ..i n�(�i ��i� `7J g(p R:meonfrr 5i�bmimng[tile Form lt'IxaM Cl�ei <br /> Fsciuty Phanc N: 3 _ �Z-� ❑ %hontc of Duigrrototi f,)pcta,or i <br /> � C U d�a�ccrtificor LxninlMn Dote <br /> Desiaoated ratordtl for this Facility <br /> PRIMARY <br /> OteIr'Med Oot=t 'a Nome: ti^S.L AA `ate f Rn'.olua to VST ru�lliy,(ChetF Otil �t <br /> � 1 94ocq Wme(Udi(TrrrrrfYwrr ad,w.�: 7� Q Owncr ❑ Operttar ❑ Cmp!eyto <br /> rJae,$M:9d Oywrster'v Mona N, -r . Z- r YS s Rf Swviw'rwnnk{or. 0 ThirdAtn y <br /> Itasmllionai Cols Counsil Cvii mVI N, S 1 E■piradOn Ds[c• _ ,� <br /> A T a.NAT 1 <br /> Deolanalsd Opcnior's Nsms, Italsdon a UST Pwlliry(C4ed t7rn, <br /> 8odnees Nitric W d,,ft#TMffi" e+'w,i, e Owner ❑ Gperstw ❑ Ernployar <br /> AftNNed Operaer•o P W80!. A t L'It q-1-7 !.S f _ ar Savi:e ToeAnie!an D Thad-Pwty^—� <br /> Int@natWtl Cade CIMM11 CerCAMIOn N: <br /> ALTICRNAT11 (IOpMgrfJ �� <br /> DnAlitu d Oparstdr's Name Se f4� G..t e t Rsialwo to.'Sr p,tci:tty!Check Aq) <br /> Biww"NatndG1diper'MfCmabova/,t.��p• L'r1l_'■•�e T—=^� 0 Owner ❑ Opamr D Emptoyec <br /> DnipMed Opm a-ii Phare s: fit'!Ci fa 7 • t r s 7 ¢' Svvlcc Teehni%w ❑ TYrd-Pony <br /> lnamaoorrsl Cede Cnuncit Certlflcu�nn N: ,A-p y Enptrarion nate. <br /> I <br /> T certify that,for the facility indicated st the top of this page,the individual(s) listed above will <br /> verve as Designated UST Operator(S). The individual(s)will conduct and document inonthly <br /> facility inspections and annual facility employ=trainf& in accordance with California Code of <br /> Regulations,title 23. section 2115(c) • (f). <br /> FV"hermoM I andeestead aad ►ta in contpNance with the requirements Otatatt% <br /> regalatlonN RRd heal ovdblaeces)applitabh to andtrgrouad storage tanks. j <br /> NAM"EOfTANK Ct"tR(PlsaosPrint); UAli-FOCNIA 9?25 <br /> SICNATUREOFTANK <br /> rO�WNE,�K(/:GFII rA1! 2>T/Kr L•t C. ytt f er) <br /> DATE: OWNER'S PHONE s: 2-01 J <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL ACIENCY NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANLARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:�uW We�rr6A&`IIIkLQ7n'StL'Ssi�-3EYS.h(Cll• <br /> 2)NOTtFV TRE LOCAL AGENCV OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OPTHECHANGE. <br /> ,iovorebe-200M <br /> ,.. S0 39tfd Z a39I1 TBEIEZ8 9E:ET b00Z/6Z/ZT <br />