COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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UARGROUND STORAGE TANK0SYSTEM OWNERS STATEMENT OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS FACILITY NAME FACILITY PHONE Lawrence Livermore National Laboratory, Expermental Test Site (Site 300) (925)423-6626 FACILITY SITE ADDRESS CITY Corral Hollow Road, near 1-580 Tracy REASON FOR SUBMITTING THIS FORM(Check One): ❑Change of Designated Operator(s) ❑ Update of ICC Certification ExpirationDate(s) CA DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: ,lose Pineda RELATIONSHIP TO UST FACILITY(Check One) BUSINESS NAME(Ifdiferentfrom above): Same as above. ❑ Owner ❑ Operator M Employee DESIGNATED OPERATOR PHONE: (925) 423-7173 ext. None ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8020095 EXPIRATION DATE: 10/29/2012 ALTERNATE CA DESIGNATED UST OPERATOR FOR THIS FACILITY(O tional) DESIGNATED OPERATOR NAME: Richard Kirchgatter RELATIONSHIP TO UST FACILITY(Check One) BUSINESS NAME(Ifdii erentfrom above): Same as above. ❑ Owner ❑ Operator M Employee DESIGNATED OPERATOR PHONE: (925) 423-5247 ext. None ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5246164 EXPIRATION DATE: 02/05/2013 ALTERNATE CA DESIGNATED UST OPERATOR FOR THIS FACILITY O tional DESIGNATED OPERATOR NAME: Brian D. Thornton RELATIONSHIP TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfromabove): Thornton Environmental Construction, Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (209) 834-0792 ext. None M Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5024962 EXPIRATION DATE: 6/25/2012 ALTERNATE CA DESIGNATED UST OPERATOR FOR THIS FACILITY O tional DESIGNATED OPERATOR NAME: None RELATIONSHIP TO UST FACILITY(Check One) BUSINESS NAME(Ifdiffereni from above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL 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 CA Designated UST Operator(s)for the permitted USTs at the facility indicated at the top of this page.The CA Designated UST Operator(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 permitted underground storage tanks. TANK OWNERS NAME/AGENT: U.S. Department of Energy / NNSA / Vijay Mishra TANK OWNERS/AGENTS TITLE: Environmental Comlpiance SME OWNERS PHONE: (925) 423-8163 TANK OWNERS/AGENTS SIGNATURE: 1< 1 'r'^ DATE: O5 0/2,0 11 INSTRUCTIONS 1. List the name(s) of the CA Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available at:www.icesafe.org/e/certsearch.htmi.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's permitted USTs. Unidocs member agency jurisdictions and contact information are listed at: www.unidocs.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.xls. 3. 23 CCR §2715(a) requires that the local agency be notified of any change of the CA Designated UST Operator(s) no later than 30 days after the change. ReE UN-062 Mod.1-1/1 12/14/2010