Laserfiche WebLink
Jun.28.2013 08:08 PM Arnie Kaufman <br />I I <br />2098236964 PAGE. 1/ 2 <br />R E" EIV::D <br />Q - E <br />Owner Statements of Designated Underground Storage Tank (UST) OpeSIA?ro 12013 <br />and Understanding of and Compliance with UST Requirements <br />SAN J( AQUIN GOUI <br />Facility Natne, Country Club Mini Man Facility ID 0: EN RONME NTAJ <br />Facility Address: 1856 Country Club Reason for Submitting this Fa I I - --- rIME <br />Stockton, CA. 0520 X Change of Designated Operat <br />Facility Phone # Update Certificate Expiration ate <br />t3 R UK 1 4" <br />Designated Operator's None-. Karen R Arnsiz <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator D Employee <br />0 Service Technician X Third -Party <br />yce <br />rty <br />Business Name (!f different from above): <br />Designated Operator's Phone #: (209) 518-4836 <br />latertut(jonal Code Council Certification #: 8032295 -UC <br />expiration Date, 05/31/2015 <br />AINFRNATE I fnndamal) <br />Designated Operator's Name- <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator C3 Emp] <br />0 ServiceTechnician C3 Third -Pi <br />yce <br />rty <br />Business Name (! different from above); <br />Designated Operator's Phone #; <br />#International Code Council Certification 0: <br />Expiration Date - <br />in P1 I �ANK% 9 *WOMP,7,711 <br />Designated Operator's Name; Relation to UST Facility (Check One) <br />Business Name (1fdOrwn1from above): 0 Owner 0 Operator 0 f=pl <br />ayee <br />Designated Operator's Phone #: E3 Service Technician a Third -N <br />rty <br />International Code Council Certification #: Expiration Date: <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above ill <br />serve as Designated UST Operator(s). The individual(s) will conduct and document month y <br />facility inspections and annual facility employee training, in accordance with California Co Je 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); <br />SIGNATURE OF TANK OWNER`: <br />DATE: 06/27/13 OWNER'S PHONE #: <br />0 <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WA TER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAIL, WLE <br />AT: www.waterboai-ds..c�lgpylijst/contact.,/Ctipo:p�!,ys,htmi. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DA YS <br />OF THE CHANGE. <br />0=1 <br />