Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (USTT*F'PetW?005 <br />and Understanding of and Compliance with UST Req <br />!L,W_qEV =-MrAn Facility ID #: <br />VI Reason for Submitting this Form (Check One) <br />0 ange of Designated Operator <br />Update Certificate Expiration Date <br />Desipated UST Operator(s) for this Facifily <br />.Iq" oil 14iJ.'s <br />0 0%,.,ner El Operator 0 Employee <br />o Service Technician r -I Third -Party <br />BusincssNameWdifferen1from above): <br />I-- - - <br />I Designated OpwAor's Phone #* <br />international Code Council Certification #: <br />11 Expiration Date-: <br />ALILMMAILL urrur <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 owner 0 Operator 0 Employee <br />0 Service Technician 0 Third -Party <br />Business Name (Ifdiffereniftom above): <br />Designated Operator's Phone 9: <br />International Code Council Certification #: <br />Expiration Date: <br />I certify that, for the facility indicated at the top of this page, the infual(s) listed above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />ff,A,iiOance with California Code of <br />Regulations, title 23, section <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 <br />OR OWNER'S AGENT (Please Print): <br />DATE: /J� 1>_V OWNER'S PHONE L <br />I XV � <br />IRE1` �r,. <br />4 <br />