COMPLIANCE INFO_1996-2008 - Laserfiche WebLink

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Dec 29 04 05:02p Alex 9 551-7892 p.7 Owner Statements of Designated Underground Storage Tank (USI) Operator and Understanding of and Compliance with UST Requirements Facility Name: % ® J Facility ID #-. Facility Address:1j+377 W,%ZZ}of Reason for Submitting this Farm (Check Orae) j`ivL.C'%lls� G '/fs' }So�4S ® Cbange of Designated Operator Facility Phone #: Q Update Certificate Expiration mate Deggggated UST ftratodsj for this F . 'tv Designated Operator's Name: 410.1 A6$ Relation to UST Facility (Check One) Bminess Name (#"different from above): �yJD �� 10 Owner ❑ Operator ❑ Employee Designated Operator's Phone 4:�r ❑ Service Technician VThird-Party International Code Council Certification #: j Date: 1 p `1 — A Designated Operator's Name: Relation to UST Facility (Check One) D Owner ❑ Operator O Employee O Service Technician ❑ Third -Party Business Name (tf4Wentfrom above): Designated Orator's Phone #: International Cade Coundl Certificatim #: Expiration Date: Designated Operator's Name- Relation to UST Facility (Check Ore) ❑ Owner O Operator ❑ Employee ❑ Service Tedmician ❑ Third -Party Business Name (If differentfmm above): Designated Operator's [Notre #: International Cade Council Certification #: 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 Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility q ployee training, in accordance with California Code of Regulations, title 23, section 2715(c) - Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER OR OVMER°S AGENT (Pune, Print):,. o- k-, J h) PFf ij'l.3H SA 10 j SIGMA OWNS DATE: September 2004