Laserfiche WebLink
hec 31 04 02: 13p Canepa 's Car Wash (209) 948-1464 p. 2 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nam: n e Q -LjL3 Facility IDO: <br /> Facility Addre": &;t-,)o 'PAC t-P Cr--Ave , STUD R—I-Sobuitrins 11%111.(ChECk O'W <br /> Q 0 Change of Designated Operator <br /> Facility Phone 0. az 5!gi ygn. 0 Update CaWficeto Deft <br /> Dghatad!VS]L QRnjj2dsj for Ibb FndlitY <br /> MMARV <br /> Desilpmactl <br /> Operator's Nanta: 7o-71 Sarv-he- <br /> Relation to UST Facility(Cheek&W <br /> Bushm Nam(0,4TWO-fivat above): 0 Owner 0 Oixiasm D Fasploycc <br /> D"itniew Operator's now# ate cl- ejq&, <br /> 0 Service Technician )!2hiN-Party <br /> banational Code Council Catificsition 0: D40"tion]DOW: <br /> ALTERNATE I(00daime!) <br /> DcAgnsaetl <br /> Operator's Name: Relation to UST Facility(Check One) <br /> Busiam Name(1fdWaromfivar above): 0 Owner a Operator 0 xinployee <br /> Dc3igratod Operator's PhoDc#: 0 Service Technician 0 Thirti-Party <br /> 'niemdf <br /> d ccdc Ccour�o!! f7-7, <br /> ALTERNATE 1000=0 <br /> Designated operator's Nam: Rotation to UST Facility(Check Otte) <br /> Business Name(Y4496wnfram above): 0 Owner 0 Operator 0 Employee <br /> Desigmacd Operator's Phone jh: 0 Service'technician D Tbint-Parry <br /> lummational Code Council Certification Expiration pate: <br /> I 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 conduct and document monthly <br /> facility inspections and annual facility employee training,in accordance with California Code of <br /> Regulations,title 23,section 27 1 5(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(Plemsme PAM): <br /> SIGNATURE OF TANK OWNER: NZ—>n t4%C� e"h Ajl 6 <br /> DATE. owrmit-s PijoNr&e: <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,1003.TI iE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: upp agys-htm- <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> Or THE CHANGE. <br /> November 2004 <br />