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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) FACILITY .IT� ME c�I�p''•}"'/'� �� rACI� 'PI-]ONE FACILI'T'Y SITE ADDR FSS CITY .00o yp�eAke mnkc4 REASON FOR SUBM rTING THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: 45�r.c_ a • v%_ RELATION TO UST FACILITY(Check One) BUSINESS NAM13(tfdierentfi-oniabove): ❑ Owner Operator ❑ Employee DESIGNATED OPERATOR PHONE: (etas ' ® ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL,CODE COUNCIL CERTIFICATION NO.: S -j q00 V c- EXPIRATION DATE: 'r ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) _ DESIGNA'T'ED OPERATOR NAME: RELATION TO UST WILITY(Check One) BUSINESS NAME(tfdriferentfronzabove): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPE_RA_TOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Rl-,LATION TO UST FACILITY(Check One) BUSINESS NAME(Ifd(/ferenifi•onvabove): ❑ Owner ❑ Operator ❑ Employee D OPERATOR PHONE: ext, ❑ Service Technician Third-Party DESIGNATE INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DA'T'E: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERA'T'OR NAME: RELATION'T'O UST FACILITY(Check One) BUSINESS NAME(/fdprent from above): [❑ Owner ❑ Operator ❑ Employee DF..SIGNA'T'ED OPERATOR PHONE: ext. ❑ Service"i'echnieian ElThird-Party INTEiRNATIONAL.CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operntor(s). The Individual(s)will conduct and document monthly facility Inspections and annual facility employee training in accordance with California Code of Regulations,Title 23,Section 2715(c)through (f). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: C T_ 7�4—IC-0%C ,'CU �. 5PUyAcae �\UW SA!$ ®F' I1 ,L L<. TANK OWNER TITLE: wlz>—S� OWNER PHONE: (: 7 TANK OWNER SIGNATURE: DATE: !(p INSTRUCTIONS I. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council(ICC).ICC certification information is available on-line at:www.iccsafe.oi•g/e/cei,tsearcl;i.litmi.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidoes.org/aneinbers/wlioregulateswilat.litmi. Contact information for other_ local agencies within California is available at:www.swreb.ca.gov/cwpliome/ust/contacts/does/local_agency_list.XIS, 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. UN-062-1/I www.unidocs.org 09/22/05