Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />Facility ID #: <br />Facility Address: I '—+oo <br />Chi !95-33(= <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />W Update Certificate Expiration Date <br />Facility Phone #: <br />Designated UST Operator(s) for this Facility <br />N R I L9 /_11 Ali <br />Designated Operator's Name: Robert Barnhart <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />x Service Technician ❑ Third -Party <br />Business Name (If different from above): Reliable Petroleum Services Inc. <br />Designated Operator's Phone #: 209-604-9336 <br />International Code Council Certification #: 5252540 -UC <br />Expiration Date: 12-23-2011 <br />ALTERNATE, 1 (nntional) <br />Designated Operator's Name: Guadalupe Sanchez <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />x Service Technician ❑ Third -Party <br />Business Name (If different from above): Reliable Petroleum Services Inc. <br />Designated Operator's Phone #: 209-604-9363 <br />International Code Council Certification #: 5250451 -UC <br />Expiration Date: 01-29-2013 <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 />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 (Please Print): q 74 ,`` J ®®e e® <br />SIGNATURE OF TANK OWNER: v <br />DATE: -' ® Z — 1 <br />I I <br />OWNER'S PHONE #: ' �, <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.watei-boards.ca.gov/ust/contacts/cupa U sem. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />