BILLING PRE 2019 - Laserfiche WebLink

Home Browse Search

RECEIVED UNDERGROUND STORAGE TANK SYSTEM APR 19 2013 OWNER STATEMENTS OF DESIGNATED UST OPERATOR ANIENVIR®NMENTAL UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENMLTH DEPARTMENT For use by Undoes Member Agencies or where approved by your Local Jurisdiction Authority Cited- Ttle 23,Div,3,CA 16 California Code of Regzdations(CCR) � F&b4q lIT1 aY NAeM_E 1�J21xcSr�ac�reT'r�teCFACILITY mPHiO}NE cl 5, - 15`. 51 FACILITY ADDRESS Briv ocK�anREASON FOR SUMIT7TNG I THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Date(s) 1 PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: / �N f/ 1� �ATION TO LIST FACII tTY(Check One) I BUS SS NAME(fd fferent from above): 7t l �crr7 (Jt" pl Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONIs: 20 R 1 S� ,6 ]�Service Technician Third-Party l ext, INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: O 10� EXPIRATION DATE: 2, 2,9 1,Y ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(O DESIGNATED OPtinrtal ER4TOR NAME: A,? �' RELATION TO UST FACILITY(Check One) BUSINESS NAME(tf dr feren(from above): / r� no,�� dn1 "74C ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: �� } j- eXt ❑ SeMce Technician Third-Party —�3 INTERNATIONAL CODE COUNCIL CER i IFICATION NO.: 3 3 EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) S hG Z� ZO/ DESIGNATED OPh2ATOR NAME: ` ✓ 151 RELAIION TO UST FACILITY(Check One) BUSINESS NAME W differenUrom above): Nd, ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (Zp .?7—' 7y ext. �ServiceTechnician Third-Patty INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DALE: ALTERNATE 3 DESIGNATED UST OPERA'T'OR FOR THIS FACILITY(O tionao DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAMEW&fferentfromabove): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ext. Thi( } ❑ Service Technician ❑ rd-Party 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 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: TANK OWNER TITLE: OWNER PHONE: r TANK OWNER SIGNATURE: DATE:_ INSTRUCTIONS I. 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.icesafe.org/e/certsearch.htrnl.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 contact information are listed on-line at: www.unidoes-org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.Swrcb.ca-govlewphome/ust/contacts/docsAocal_agency_listxls. 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-062-III www.aaidoes.org 0922/05