Laserfiche WebLink
DEC 3 0 2004 <br /> ENVIht��Jt�� 1, i ;iEALTH <br /> PUNT iiCLRVICES <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: 19- <br /> Facility L�Address: S 3 Reason for Submitting this Form(Check One) <br /> 7 I-y)A EtQ�hange of Designated Operator <br /> Facility Phone#: CHO <br /> ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> E)esignatedOpmtor'sN=e:M'%CAjjlp ��Relation to UST Facility(Check One) <br /> Business Name(Ifditffe enl from ve): Downer ❑ Operator ❑ Employee <br /> Dcignat.-d Operator's Phone. . Service Technician ❑ Third-Party <br /> International Code Council CAfication - Expiration Date: S- 2._:E00 <br /> ALTERNATE 1 ' naf <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(ffdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opdonal) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 2713(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 OF TANK OWNER n ' <br /> OR OWNER'S AGENT(Please Print): l � �- <br /> SIGNATURE OF TANK r � <br /> OWNER OR OWNER'S AGENT: /1 <br /> DATE:�Z-Z�--�I OWNER'S PHONE#. :5 <br /> September 2004 <br />