Laserfiche WebLink
y+ V <br />AIV <br />JUL 17 2009 <br />SAN JO/1,QLtiN COUNTY <br />EN'iii' ^NkiENTAL <br />�EAL;t�1Aifr,;'f <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: N/^ Facility ID #: <br />Facility Address: -~ P ►Reason for Submitting this Form (Check One) <br />q{ Change of Designated Operator <br />l--acility Phone #: ❑ Update Certificate Expiration Date <br />Designated UST O erator s for this Facility <br />rrutvri+rc r <br />Designated Operator's Name: (Z�`i\% -f ZS <br />Relation to UST Facility (Check One) <br />Owner ❑ Operator ClEmployee <br />❑ Service Technician hird arty <br />-11 <br />Business Name (If dijferenl from above):❑ <br />GG <br />Designated Operator's Phone #: 9-0 -k — -/ Li —1 —7 <br />International Code Council Certification #: 0 L. 6 5 .—LIC <br />Expiration Date: d <br />A11A P, ml. -tar• r up -jun.." <br />Designated Operator's Name: <br />Relation to UST Facility (CheckO+>e) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If &fJerenlfromabove): <br />Designated Operator's Phone #: <br />International Code Council Certification #; <br />Expiration Date: <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Parry <br />Business Name (If chfferenl from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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 2715(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 (Please Print): K o <br />SIGNATURE OF TANK OWNER: .i _ <br />DATE: ! �� fI OWNER'S PHONE #:� <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: a'ww waterboardc ca uovlusVeontac L-,/cuna atays.btntl. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />I -d <br />