Laserfiche WebLink
08/22/2012 11:43AN FAX 2093330318 KSX CORP Q 0002/0008 <br /> UNDERGROUND TO GE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED IST OPERATOR AND­ <br /> UNDEMSTANDING OF AND COMPLUNCE WITH UST REQUIREMENTS <br /> For use by undmv Member Agencies or where approved by your LW17I JurL d ot!O, <br /> Authority Cited: Title 23.Div.3,Ch, 16 California C4sde of Re ons(CCR) <br /> FAC1177YNAME FACILITY PHONE a <br /> Kettelman Chevron (`. 97 33 <br /> FACIUTY SITE AADRFS.S <br /> 601 E. Kettelman Lane Leri <br /> ttTASt)N FOR fiIJBAMiT 17NG THIN FORM(Check aw): C'6angc of DeslSWcd iJpdatc of lcc Ccojf=tion Expiradm 1?ste(s) <br /> PRRMgY DESIGNATE.0 UST OpERATOR FOR')i`HIS FACILITY RRLAXION TO UST FACILITY(Check Ow) <br /> I IGNA'I'EDOP8P.ATORNAME- Alex iabbarl <br /> BuswussNnME(/fdwrm n <br /> d): Norval Petroteurn Sen , Inc ❑ Oww ® ° 0' l3 rmP <br /> DESiGNATF.6Fx RAT('KPIIow (925)389-1262 eat, ® saviocTecw ❑ -nim-y <br /> I9rERNATTONAI.CODE WUNCIL CERTIFicxrm No.: 5243897UC rxPIRATJON DATE: J pWp 1 2 <br /> ALTERNATE i I)ESICNATED UST OPERATOR FOR TMS FACILITY <br /> ItR[AT[ON 7'C}t{ST FAC.1l.i'IY(CfxxkUlUna) <br /> JwMIGMATRD OPERATOR NAME: <br /> BUSINESS NAME(!fdffvenrj+aw abuw): ❑ Owner ❑ opmw ❑ <br /> DEsmNATEDOFERATORPIi)Nr-: Savice'I'cc Inicimn ❑ Tgirdtl'arty <br /> Dn FRNATIONAL CODE COUN(:II,CERTIFICATION NO.: TION DATE. <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR TMS FACILITY <br /> MSIGNATBts 6;5AT6R NAME; RLLATION To U57'FACILITY(Check Ow) <br /> StJ3INISSNAMF(IfdijJercmfMwabnye): ❑ Owner ❑ Operawr i❑-I Employ= <br /> DPhu,NATEDOPPRATORPHQNR: ( } act. ehn❑ SomiceTciciasn Third-PaTty <br /> INTERNATIONAL CODR(MUNCIt.CERTIFICA'fJON NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED US'T OPERATOR pUR THIS FACMITY( ) <br /> DggiGNATED OPRRA IX)R NAME: RMATION TO UST FAC[Lri•Y(Cheek fes) <br /> IxUSINESS NAME(lfdg rrerat from abow)! ❑ owner ❑ OMatm ❑ Finp <br /> DF51C,KATED OPERATOR PHONE. ( } ext, ❑ Semi a'technician ® '11h4-PwLy <br /> n,rrMA7'iONAL CODE COUNCIL CGRTIFICA noN NO.: FXPIRATION DATR: <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 /> Uperator(s). The i nal(s)will conduct and document monthly facility inspections and annual facility employee trnilsift <br /> in accordance with Kalifornia Cade of Regulations,Title 23,Section 2715(c)through(f). Furthermore,I understand <br /> ' <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tank56 <br /> TANK O INAM$: q;w" <br /> TANK OWNER TITLE: OWNER PHONE: �'ot `a 03ta� ' <br /> TAMC ON&DW SIOINATURE: YY'r DA TE, - — <br /> INST TIONs <br /> I. Report the name(s)of the Designated UST OperaWr(s)as registered with t11:e International Code Council(ICC). ICC certification <br /> inf(}rmation is available on-line at wwwiccsafe.org/e/ecMearch.html.Search for"California UST System Operators." <br /> 2. Submit this completed form to the local 8Vncy that regulates this facility's IJSTs. Unidocs membor agency 3uriShcCtions and <br /> contact information arc listed on-line at: www.unidocs.org/memberstwhorePlateswhat.lktml. Contact information for other <br /> local agencies within California is available at www.swreb.ca.pv/cvvphomevst/cOntskeb/dOadlOW-,.PgcncY-j6tAls- <br /> 3. 23 CCR§2715(a)rewires that you notify the local agcney of any changes to this information within 30 days of the data ofohange. <br />