Laserfiche WebLink
�rL"��° PAGE 01 <br />DEC 2 9 2004 <br />rnn- ��P.t rel <br />awt7er Staty MnzS of Designated Underground Storage Tank (UST) Operator <br />and Understanding at and COmpliance with LST Requirements <br />anatli�yNe4(,/a �,str .�.0 F"fiityl0#. A _ <br />hdi,ly tidCnny; <br />�/ �p MAl`1+,e�,4 G4 , Itanno fro SubmirtinE this Form rt 4ec1 One) <br />Ll E, loSEf'{t ' `-, Alt 9 J�33 Q Cyanic of Dcgiaiact �DcYaTot <br />Fateitit/ Phmc 0: LCA '& — C - date Certificate Cxpiration Dace <br />2ftiff"Udre p f i <br />)MARY <br />De staved Orwe WW'a 4' v tc: — - Ce% <br />Bwintwe VeR1c ((/d�irrewr fiw�► ahriv i. o=02LfP fX <br />ties-�rsstod s�trrtttrr'i Phare ;s, ji r Li 1 a � • ! s r 7 <br />lrumatloow Core Courter cavi lcAwl r: 5 d M e, < < d . <br />Desipad Optxewr's Nems: 4 Yc,2 M, j, at, e,6 <br />Husineaa Netto aMre; j of , sa <br />.... <br />I ow <br />d Uptleaer a E'hone ry: (1, L t 6% 7. 4 g f6Y <br />irtsmatWtlal �� f;�tIRCIS bflihY`h�t� �� � fT IL A �rT /'L: G �.� <br />ALTERNATE (Vp1&Pt09 <br />Nft aaed Oparxur.'n Name: <br />�Mli'►tea Ntene (jrd1;Q'iNM l.+am cbovej. �,,�,w—� /, as �re e.a•� <br />tkr+isaued operwcrr'aPhonei._(iLft1 S�-7 - c s?_ r-- _ <br />Irtternedotllj Code CAU"d Car ificatinn CA4 -- <br />Untion to UST rac+lity (0ecA Ony --- -� <br />0 Q*n- 0 Opor,tor 0 P-m9leyae I <br />IR servico,rmnidar, 0 1hi►d.�lt4y� <br />E1plr80pn Dow 4- I ? 0 6 I <br />Rolulo7 to UST Fecal Icy (C*a AOrn) <br />C Owner Q Operator O &nPloyOr <br />R 9arvkc Technivan O Ybud-ttrty <br />Expiratim Dau: , 1 �► - t "l -V'�— <br />Retaiaa to'—'S'T Frau:10 (CArcA O-er <br />c owner c Opermor 0 EMP16y'eo 1 <br />P' 9avkc raehmtwd a fhird•Perty {I <br />Ex;itetion Daft I i • tt -*L <br />I certify that, for the fecility indicaLs;Id at the top Of thio p4ge, liar Wivi&W(a) listed above will 1 <br />smc as Desipated UST C)perator(s). The hidividua<l(a) will conduct and document monthly <br />f@tility inqmctions and annual facility eroployec uaining, in accardsnce with CraVifotria Code of <br />Regulations, title 213, !Cation 2715(c) - M. <br />f FvrthermoM I andentaaid and Oat its campl anee with, the rogUirements (stattites, I <br />rt pj&tion:, Nand keel ordinances) sippWhle to vad*Mmo td storage tanks!. <br />NAME OF TANK DwNsR (mue rrnnt)i U; -Fowl <br />til <br />SICNATURZ Olt TANK OWNER: L+SifWWfA 3KLj=on1. <br />DArE, 12l-aq�0� OWNER'SPKONr <br />w <br />NOTE: I) $UBA41T THIS COMPLETED FORM TO THE LOCAL AGENCY i.NOT THE STAn WATER <br />RISOC!RC1ES CONTROL BOARD) DY JANGARY t, 20K THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: T.6X �sl�b4drsls..0 issues 0rr��;Qa �iY�- <br />2) NOt7FY INK LOCAL AGENCY OF ANY CHANO :3 TO THIS INFORMATION W)THIN JO DAYS <br />OF T'NE CHAN'M <br />:► OVOM5" 204 <br />Z0 30dd -- Z H39U T8£T£Z8 9£:£T ti90Z/6Z/ZT <br />