Laserfiche WebLink
2 <br />v <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: — S 4 ✓}rz i< I <br />Facility ID #: <br />Facility Address: �Jc �e , J �,2R yL <br />j f,4A)V� C.Pq C j �6 <br />Reason for Submitting this Form (Check One) <br />[)Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: �2 b ? - a Z 2_ 7 6 2 K <br />Designated UST Operator(s) for this Facility <br />Designated Operator's Name: Sok % #,oc61" cd <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Third -Party <br />Business Name (If different from above): WqZ ,jA{ �Ei;JAa2fa —Dtc < <br />Designated Operator's Phone #: c116 —,372_ <br />International Code Council Certification #: Sr , 4&,qc1). c/ Cj,iR Ls: <br />I Expiration Date: 6c/d 6,t2 /Z, 2 oo 6 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If d fferent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 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 <br />OR OWNER'S AGENT (Please Print): A11/9 �i`<�� �V <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: /J,4�C , 2z 0001 OWNER'S PHONE #: <br />September 2004 <br />