Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with <br />'Vft1iWT% <br />Facility Name: VA bL-e `/ AQC D <br />F40ity ID -4., . . <br />Facility Address: /lo e • FIA901A14, WO S/�eap�i�dt <br />S TpGK tp/V CA of Z O �/ <br />Snbn-dtt4i4 orm (Check One) <br />c'� Change ofDesi n�a ec bpTerator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 26x'l . y - qS-( <br />Designated UST Onerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Karen R. Abbott <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician % Third -Party <br />Business Name ([f different from above): <br />Designated Operator's Phone #:(209)518-4836 <br />International Code Council Certification #:5266643 -UC <br />Expiration Date: 10/12/07 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name ([f different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name ([f different from above): <br />Designated Operator's Phone #: <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) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME <br />SIGNA' <br />DATE: <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/ust/contactsicupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />