Laserfiche WebLink
} <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST)Kcquiremrmts <br /> Facility Nittnn: � c �$5 _ Facility IU 9.: _ <br /> __� .__ <br /> Facility Address_ Reason for Submitting this Form{CheciC One) <br /> o /y]T sT✓far"� o,d?a She k Change of Desipated Operator <br /> 1'ncilityPhonc#: � � '��"ys _v ❑ UpdnteCeniticurcl3:piratienDate <br /> Doxiitnstted_UB Obarator(s)for this Facility <br /> Dosigttatud Operator'u Namc: Gelation to UST Facility,(ChunkUncJ <br /> Business Nttmc(ffdi/ferenr from above). Q TO f G}Q -_-re_g_4- ti owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 1f Y('Z p q) I Lfq -C5 I l 2 y Scrvtco Tcahniriaa O t-hlydd'aljy <br /> IntOmatlont)Codd Council Certili ITi0h# /��! J ;y 7- Expiration Done_ J <br /> ALTERNATE] t?firma _ <br /> Desisttatnd oper4t01's Nalrtel .7 Nom,. A,. Relation to UST Facility(ClrerkOne) <br /> 1luttinaosNatnc(1f&fferenifrnmalroy(); r� �� _ � ❑ Owner 0 Opcmtor ❑`Employee <br /> Dosipnated operates 11011011: �� -7 1-(- <br /> tuty <br /> ' > GServile Ttehnician (] 7.bird-1' <br /> Internationul 040 Council Ccrlification#: (a� J - 1�/f++ lixpvadon Alec: g, <br /> ALTERNATE 2 (Optimal) <br /> Do:lignuedOpt=tur's Ntutio: Relation to 17ST Facility(Cherh One) <br /> Duaiticm Name(Ifdaercalfrum abriver): V _ ❑ Owner ❑ Operator Q rimplayee <br /> Designated Operatneii Phortc 11. )1t Servico TocMiaian O Third-Pavy <br /> 11110teativnnl Codc Council(:criifiuttion M Expiration Hato: <br /> .NOTE:TILE LOCAs,REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INwORMAMN WITHIN 30 DAYS OFTI-IE CHANGE. <br /> 1 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 couduet and document monthly <br /> facility 1n,4paeti«ns and annual facility employee training,in accordance with California Code of <br /> Regulations,title 23,section 2715(c)-(1). <br /> Furthermore,i understand and am In compRallce with the ire(luiremcnts(statutes, <br /> regulations,and local ordinalnt'es)applicable to underground ytor flanks. <br /> NAMEOF TANK OWNER(Please PrI nt): '���� �•k�✓Y <br /> SIGNATURE OF TANK OWNILR- <br /> OWNUIVS PHONEt(-aC C7� E <br /> Novcmbcr2001 <br /> 100 'd 90I089800? �l�I X�� 'HM SSH'I HO. GOOd KV X0 :90 HOWAOH/611HH <br />