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12/22/2009 12:00 FAX 17074466192 TANK-TEK IM 004/004 <br />go 00 <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br />For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br />Authority Cited: Title 23, Div, 3, Ch. 16 Cal fornix Code of Regulations (CCR) <br />PRIMARY DESIGNATED UST OPERATOR FOR T141C IFAr',II.ITV <br />DESIGNATED OPERATOR NAME: Daniel Lawrence <br />RI -,I ATION TO UST FACILITY (ChevkOne) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Scrvice Technician S Third -Party <br />BUSINESS NAME Wdr�erenrfromabove): Tank -Tek Environmental Corp. <br />DESIGNATED OPERATOR PHONE: (707) 446-6151 ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION No,; 8026453-11C <br />EXPIRATION DA-rL: 3/14/2011 <br />ALTERNATE I DESIGNATED UST OPERATOR FOR THIS TACTILITY tnpna..11 <br />DESIGNATED OPERATOR NAME: Richard Thomas <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employce <br />❑ Servicc Tcchnician ® Third -Party <br />SU5[NESS NAME (U'digerenrfran above): Tank -Tek Environmental Corp. <br />DESIGNATED OPERATOR PHONE; `707) 446-6151 ext, <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5254736 -UC <br />EXPIRATION DATE; 1/20/2011 <br />ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) <br />DESIGNATED OPERATOR NAME; <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ® Operator ❑ Employee <br />❑ Service Tcchnician ❑ Third -Party <br />BUSINESS NAME (Ifdjremntfrom above): <br />DESIGNATED OPERATOR PHONE; ext. <br />INTERNATIONAL CODE COUNCIL cepuiTICATION NO.: <br />EXPIRATION DATE: <br />ALTERNATC 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) <br />DESIGNATED OPERATOR NAME; RELATION TO UST FACILITY (Check One) <br />BUSINESS NAME (Ijdifjerenr from above): ❑ Owncr ❑ Operator ❑ Employee <br />DESIGNATED OPERATOR PHONE; ❑ Scrvice Technician ❑ '17iird-Party <br />INTERNATIONAL CODE COUNCIL. CERTIFICATION NO.; EXPIRATION DATE-., <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br />Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training <br />in accordance with California Code of Regulations, Title 23, Section 2715(c) through (i). Furthermore, I understand and am <br />in compliance with the requirements (statutes, regulations, and local or inances) applicable to under round storage tanks, <br />TANK OWNER NAME: C ; As g CNEE PRMEM MkQTVCY1PN <br />TANK OWNER TITLE: <br />I <br />60 10;1 A;7:Ti <br />mm <br />TANK OWNER SIGNATURE: _ _ 71 DATE: <br />INSTRUCTIONS <br />1. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification <br />information is available on-line at: www.icesafe.org/e/certsearch.htmi. Search for "California UST System Operators:' <br />2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and <br />contact information are listed on-line at: www.unidoes.org/members/whoregulateswhaLhtmi. Contact information for other <br />local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/does/local agency_list.xis. <br />3. 23 CCR §2715(x) requires that you notify the local agency of any changes to this information within 30 days of the date of change. <br />UN -062 - 1/1 www.unidoet.org 09/22105 <br />