Laserfiche WebLink
P. i <br /> R! t <br /> Owner Statements of Designated Underground Storage Tanis(.WA T) <br /> and Understanding of and Compliance with UST Requt <br /> �v <br /> Facility Name: r Facility.ID#: <br /> Facility Address: Reason for Submitting this.Fa ck One) <br /> Change of Designated Operator <br /> ,Facility Phone# X Update Certificate Expiration Date <br /> Des'�nated UST O <br /> tor(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209)51$-4836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date:06111/2013 <br /> ALTERNATE 1.fflmhonao <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name: <br /> Business Name(If differentfrom above): ❑ Owner ❑ Operator ❑ 'Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optiand) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Pally <br /> International Code Council Certification#: 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 Pr.int): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE M clp­q 1 1,1 64-? _ <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.waterboai-ds.ca.Zov/ust,contacts.,cupa gvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />