Laserfiche WebLink
ia.ia,cUV4 12: 12 A bb1363`5467 DJA INSPECTION_^ PAGE 02/04 <br /> DEC 14 2004 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements ENVIRONMENT hEALTH <br /> PERMIT;SERVICES <br /> Faeiuey Nsme: <br /> Facility In 4; baa o 6 <br /> Fact ty Address: , Room for Submitting this Form(Check One) <br /> do IAi' r TUY ✓ S}e A Loot, Of- g5,NV te�Chante of Designated Operator <br /> FacilityPhone#: 90,?2 36q-,36 A ❑ Update ecrti9cam Expiration nate <br /> Desianated UST Oneratorfs) for this FAeility <br /> PRUdARY <br /> Deaipmed Operator's Name: JOEL CRAWFORD Relation to UST Facility(Check One) <br /> Raainees Name(If different from ahmt):CHAMPION PRECISION 7MV11wi IN(7 ❑ Owner ❑ Opaalor ❑ Empinyce <br /> Designated Operator's Phone#: 916.927.1557 Servitx'1'echnicion ❑ Third-Party <br /> International Code Cotrocil Cenilication 4: 5240664-IJC Ex*xIion Date:O8/17106 <br /> ALTERNATE (ApolywO <br /> Dosignoed Operator's Name: JEFFREY GATES Relation to UST Facility(Check Om) <br /> Business Name(If dV&enrfrom above): CrrlWj0N rRECJ8loN)ra7ING JNC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Fume#: 91&927-1337 R Sorvim Technician ❑ Third-Party <br /> International Cudc CoundI Q:ttitication0: 555497689#APPLIED FOR Expiration Dew: 11/11/06 <br /> ALTERNATE2 (Optlexal) <br /> Designated Opernor's Nome: Relation to i.IST Facility(Check Ohre) <br /> Susirs:ss Name(lfd!fferantfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Desirated Op:rator•s M=e 4: ❑ %ervice Twhnician ❑ 'Third-Party <br /> b1tcmational Code Ceuneil Certification 0: L'Xpimiun Date: <br /> 1 certify tbat, for the facility indicated at the top of this page, the individuals) 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 aaderstand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to under%round storage tanks. <br /> NAME OF TANK OWNER(Please!t): <br /> SIGNATURE OF TANK OWNF. - <br /> DATE: 1a -13"° 7 oaNEWS PHONE' <br /> +t: aoq �3go9i— <br /> NOTE: 1)SURMITTHIS COM FIXTEDFORM TnTHE MCA.L AGCNCY(NOT TH F STATE WATl,',R <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005,THE LOCAL AGENCY LIST Is AVAILABLE <br /> AT:alit-•.wpteritr)ards ca sovhmUcontacrs/M aivs.httnl. <br /> 2)NOUT3FY TI!V!.0"AL AL-ENS:Y nc..ANY CHANGES TO THIS INFORMATION %At!TH.IN 30 <br /> OFTHECHANGE- <br /> Nvvembcr 2004 <br />