Laserfiche WebLink
y � � <br /> Jan 14 08 02: 56p AfAftrda Test (20o 744-0116 p. 1 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Facility Addrew kca%m for Submitting this Form((:heck One) <br /> Change of Designated Operator <br /> Facility Phone <br /> Designated LUST Operatorfs)for this_Faeillity- <br /> PRIMAIRY <br /> Designated Operator's Name: David A.Winkler Rclation to UST Facility(Check One) <br /> Rwiiness Name(Ifdlf Brent front obave): Aifforda-Test Service Technician <br /> Desig:tated Operator's Phone#: 209 74"112 <br /> International Code Council Certification#: 5263373-UC Expiration Date: 3/3/08 <br /> ALTERNATEDt}oeal <br /> Designated Operator's Name: Zane A.Nimmo Relation to UST Facility((:heck One) <br /> Businm Nome(if differentfrom above); —Afforda-Test <br /> Designated Opctator's Phone#: 249 744-0112 Service Technician <br /> Intemalional Code Council Certiliadion#: 5263.122-M Expiration Date: _ 2/3/0$ <br /> ALTERNATE 2 (Opdonall .,. <br /> DesignatedOperator's Name: Lyle 0.Nimmo Relation to UST Fau;ility(Check One) <br /> Business Name QF4fferent frum above): A O a-Test <br /> D ignated Operators Phone#: 209 744-0112 Service Technician <br /> International Code Council Certification#: 5249115-UC Expiration Date: 7/1/09 <br /> I certify that,for the facility indicated at the top of dais 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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2W5.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.witcrbo.irds.ci.i-,ov/tist/coiii-,vctq/ctii)i_ipys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHEIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />