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- i ii UNDERGROUND STORAGE TANK SYSTEM 1i OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS i T For use by Undoes Member Agencies or where approved by your Local Jurisdiction Authority Cited.. Title 23,Div 3,Ch.16 California Code ofRegulations(CCR) FACILITY NAME FACILITY PHONE ( ) FACILITY SITE ADDRESS CITY t REASON FOR SUBAETIING IRIS FORM(Check One): ❑Change of Designated Operator El Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: t wt,, /•l i'-1r_ tet RELATION TO UST FACILITY(Check One) BUSINESS NAME(.(I'd((/erent from above): borl RIM11 Owner El Operator El Employee j DESIGNATED OPERATOR PHONE: ( 2c,9 ) 5�,��je�� ext Y1Sl Service Technician Third-Party I i INTERNATIONAL CODE COUNCIL CERTIF[CAT10N NO.: gO 1 CI/_ EXPIRATION DATE: �� 29 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY O Liana! ! DESIGNATED OPERATOR NAME:AeV RELATION TO UST FACILITY(Check One) BUSINESS NAME Wd{f event from above): Dom 6c- 1�drrl� G� �� 7 El Owner [I Operator [I Employee DESIGNATED OPERATOR PHONE: z0�f ) J'r- cJ j e 0 Service Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO: 8Q 33 EXPIRATION DATE:j-h�Z/ 201 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) I DESIGNAIEDOPERATOR NAME: �.0/ate �t^�5 RELATION TO UST FACILITY(Check One) 1 BUSINESSNAM E(Ifdifferentfromabove): ^)�. m z'Hco E] Owner E] Operator E] Employee DESIGNATED OPERATORPHONE: ZU �3'I� ^ ext. Service Technician JZ Ihird-Patty r INTERNATIONAL CODE COUNCIL CERTMCA71ON NO.: 163 EXPIRATIONDATE: Al ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) f DESIGNATED OPERATORNAME: RELATION TO UST FACILITY(Check One) j BUSINESS NAME(fdifferentfrom above): Owner El ❑ Employee i 1 DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician Ihitd Pat ty ❑ INTERNATIONAL CODE COUNCIL CERTIFICATION NO: 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 1 Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations,Title 23,Section 2715(c)through(f). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: i i TANK OWNER TITLE: OWNER PHONE: TANK OWNER SIGNATURE: DATE: INSTRUCTIONS i i 1. Report the names)of the Designated UST Operators)as registered with the International Code Council(ICC).ICC certification information is available on-line at:www.icesafe.org/e/eertsearch.html.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and I contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.html. Contact information for other � local agencies within California is available at:www.swrcb.co.gov/ewphomelust/contacts/does/local agency_lisLxls,. 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. UN-OG2^ill www.unidocs.org 09/22/05 j f3 1 ! I