COMPLIANCE INFO 2006 - 2012 - 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 Unidoes Member Agencies or where approved by your Local Jurisdiction Authority Cited• Title 23, Div. 3, Cit 16 California Code of RegldafiOns (CCR) FAcrLrry NAME 5 w P - / Q QrA nr K&,rT I FACILITY PHONE ( ;269 ) LiG-7 _ o3o5 FACILITY SITE ADDRESS CITY -StdQkTo n REASON FOR SUBMITTING THIS FORM (Check Orae): N Change of Designated Operator LJ Update o€ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY RELATION TO UST FACILITY (Check One) DESIGNATED OPERATORNAivtE: Al@X Jabban BUSINESS NAME (IjdiffeF1eWfromabove): Nofcal Petroleum Services, Inc. ❑ Owner EJ Operator El Employee DESIGNATED OPERATOR PHONE: (925) 389-1262 ext 7 E] Service Technician ® Third-Party WM NATIONAL CODE COUNCIL CERTMCATION NO_: 5243897 -UC EXPIRATION DATE: 1012/2008 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: BUSINESS NAME (ydifferent,from above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: BUSINESS NAME (If different from above): DESIGNATED OPERATOR PHONE ( ) ext. R�TERNATIONAL CODE COUNCIL CERTIFICATION NO.: RELATION TO UST FACR.ITY (Check One) [] Owner [] Operator ❑ Employee ❑ Service Technician ❑ Thtrd-Party EXPIRATION DATE. RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑Third -Party EXPIRATION DATE: I 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 traiaieg in accordance with California Code of Regulations, Title 23, Section 27I5(c) through (1). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANK OWNER OR OWNERS AGENT NAME �, S wa✓n sr•�� k TANK OWNER OR OWNERS AGENT TIME: OWNER/AGENT PHONE: ( 2 2q TANK OWNER OR OWNERS AGENT SIGNATURE: INSTRUCTIONS DATE: 6 - 01 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/c/cerbvarch.htmi. Search for "California UST System Operators" 2. Submit this completed form to the local agency that regulates this facility's USTs. Undoes member agency jurisdictions and contact information are listed on-line at: www.undoes.orgimembers/whoregulateswhat.html. Contact information for other local agencies within California is available at www_swrrlb.ca_govlewphome/usVeontectsldocsllocal agency_1ist . 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.