BILLING 2012-2015 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR)------------------ FACILITY NAME FACILITY PHONE Tower Mart# 886 (209) 823-2057 FACILITY SITE ADDRESS CITY 1434 W. Yosemite Ave. Manteca, Ca 95337 REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC CertifieatiohiE'xpiradonDate(s). - PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATEDOPERATORNAME: Anthony (Paul) Chevalier RELATIONT'O UST FACILITY(Check One) B13SINESS NAME(1fdi�erentfronrabow): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (916)285-7402 ext. 181 ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252195-UC EXPIRATIONDATE: 1/17/2014 ALTERNATE.I DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Ryan Monte RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdieremfrom above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (530) 518-1177 ext. ❑ Service Technician 0 Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8182860-UC EXPIRATION DATE: 11/15/2014 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Carolyn O'Neal RELATION TO UST FACILITY(Check One) BUSINESS NAME(1fdi�eremfrwn above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (916) 316-5504 ext. ❑ Service'rechnician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8004570-UC EXPIRATION DATE: 1/2012014 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Denise Esse RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdiemntfrom above): ❑ Owner ❑ Operator ® Employee DESIGNATEDOPERATOR PHONE (916) 849-1724 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL COOP.COUNCIL CERTIFICATION NO.: 8093066_UC EXPIRATION DATE: 8/3/2013 1 certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations,Title 23, Section 2715(c) through (t). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANKOWNERNAME: Nick Battaglia TANKOWNERTITLE: GeneralMana er OWNER PHONE: 916 285-7402 TANK OWNER SIGNATURE: DA'L'E: January 1, 2013 INSAUCTIONS 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council (ICC). ICC certification information is available on-line at:www.iccsafe.org/e/certsearch.html.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhaLhtm]. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docsAocal_ageney_list.xls. 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062-1/1 www.unidocs.org 09122/05