Laserfiche WebLink
Owner statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name / , • ,t �., `„ , d: .' f i# °s Y %_ <br />Facility Address; <br />Fnoility If) #: <br />Reunn for Submitting this 1•'ntnl X' 'hock Ona) <br />q Changs of Designated operator <br />O Update Celtificuta Expiration Date <br />Facility Phone N; % f�" <br />DesW)Ated MST Querator(s) fqr this Facility <br />PRIMARY <br />Designated OpGtaiar's Name: %,-%v,f <br />Relation to UST Facility (Che( Onei <br />Business Name (If&fferenf from abo!nj a 5 . �%��r•�r _.. <br />0 Owtler ❑ Opcmtor ❑ Emplrrycc <br />Q Scrvicc Tochniuiun 11ird-Party <br />Designatud Operator's Pllone M. 5 / f .. rz,',..'j <br />Inlernational Ccdc Council Certification #:1 <br />r <br />Expiration Date: <br />ALTERNATE 1 FOaionaD <br />Designated Operator's Nat= <br />Relation to LIST Facilily (Chock Otte) <br />❑ Owncr ❑ Operator U Employoo <br />❑ Servine'I'cchnician ❑ Ibird.Party <br />Business Name (If &fferent from above).- <br />Dcsisnated Operator's Phone #: <br />Internatinnal Code Council Cortlflcation #; <br />F,xpiratian Date; <br />A I,TCRNATE 2 (OpeianaO <br />Dt%ignsted Operator's Name; <br />Relation to UST Facility (Chock One) <br />Q owner Q oporator ❑ Employes <br />❑ Sarviao'fcchniciatl ❑ Third-t)al'ty <br />Businos NurnC (Ifdifferemfrom ab&x): <br />Designated Operator's Phone #; � <br />]ntarnational CcKk Council Certiticadon #:.._ <br />Expiration Data: - -- <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO TH19 <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />1 certify that, for the facility indicated at the top of this page, the individual(s) listed above wi11 <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 />Regidations, title 23, section 2715(c) (f). <br />Furthermore, Y 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 OWNER'S AGENT (Pleaseprint) _ (�(! <br />STUNATURE OF TANK � <br />OWNER Olt OWNER'S AGENT: <br />DAT j /0OWNER'S PHONE #:4-11 <br />September 2004 <br />�d Wd62:Z0 900E bZ ':IaC B17SE UZZ 9T6: 'ON Xdd 39NUN31NIbW N0IiU1S39I01 E1S'Z'S: W <br />