COMPLIANCE INFO_2009-2015 - Laserfiche WebLink

Home Browse Search

UND,S GROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction 40 Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR JI FACILITY NAME FACILITY PHONE Tesoro/Shell#68151 (209) 369.1525 FACILITY SITE ADDRESSCITY 35 N. Cherokee Ln Lodi ENVIROMAEWAil REASON FOR SUBMITTING THIS FORM(Check One): Ig Change of Designated Operator Update of ICC Certifi PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Maria Cuarnelli RELATION TO UST FACILITY(Check One) BUSINESS NAME(1fd{gerent from above): Service Station Systems ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)971-2445 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 815'58671-UC EXPIRATION DATE: 5/11/2014 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(o tianal DESIGNATED OPERATOR NAME: ®avid Thomas RELATION TO UST FACILITY(Check One) BUSINESS NAME(l/'d(*rentfromabow): Service Station Systems ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408) 971-2445 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5258566-UC EXPIRATION DATE: 6/18/2014 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: "S_ RELATION TO UST FACILITY(Check One) Usk BUSINESS NAME(1fd(,ferent from above):et V t ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( } - (� ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 3-vc— EXPIRATION DATE:— 12s r� ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME Ufd(femntfrom ahovoe): ❑ Owner ❑ Operator [3 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 Designated UST Operator(s). The individual(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 underground storage tanks. TANK OWNER NAME: Steve Coulter TANK OWNER TITLE: EnvironmentaLAZ gmpfainpe4dministrator OWNER PHONE: 9551 538-68955 TANK OWNER SIGNATURE: T{ DATE: November 11, 2013 INSTRUCTIONS I. Report the names)of the Designated UST Operator(s)as registered with the International Code Council (ICC). ICC certification information is available on-line at:www.icesafe.org/e/certseareh.html.Search for"California UST System Operators" 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and '0contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.swreb.ca.gov/cwphometust/contacts/docs/local_agency list.xis. 3. 23 CCR§2715(x)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062-In wwwmaldocs.org 09122/as