COMPLIANCE INFO_2009-2012 - Laserfiche WebLink

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JUL-06-2011 15:25 SA26kjice Station Systems 408 938 8888 P.03 R JUL 20If Owner Statements of Designated Underground Storage Tank (UST) ®p�t- and Understanding of and Compliance with UST Require enfis Facgity Warne_ Tm Blvd Shell A Mini Mart Faclydy 0#: 135466 Facility Address: 3725 N,Tracy Blvd. Reason for Sutnnftng this Form(Goek One) TM,CA 95376 Q Change of Designated Operator Facility Phone: (209)835-7608 M Update Certificate Expiration Date w,'•',Designated UST operator($)for the f=acility;: Primary - r Dc*naW Op=Ws Norse: Dave Thomas Relation to UST FacftCheo One) Business Name(if ): Service Station Systems ® Owner 13 Operator iJ Employee Designated Operator's Phone 8: 406 971-2445 i>! Service Technician 01 Third-Party kttemat6ol Code Council CeiiAcation#: 526866&1 IC Expiration Date: 7)2112 Attentate 4( a1) Designated cls Nam: Shane Flores Relation to UST FacftChsck One) Business Name(N ftm s®ove): Service Station$ sterns 0 owner a Operator ® Employee Designated Operators Phone# 408 971 2445 18 Service Technician Eli Third-Party Intemationo Code Council Certification e: 5249001-UC 5x000n gate: 4/5/13 Alternate 2(Ogfionno Designated Opmators,Name: fforl Ca Relation to UST Facilit)(Check one) Bualness Name(it dftmnt Morn ebow): Service Station Systems Ct owner 0 Operator 0 Employee Designated Operators Phone it (40!1971-2445 tS Sef*c o Technician 2 Third-party International Cows Cound Certification#: Etgttration Date: / / i• ;Tank Fawner 1' 1 certify that,for the facility'indicated at the tap 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 aomrdance with California Code of Regulations,title 23, section 2715(c)-(f). Furthermore,II understand and am in compliance with the requirfametets(statutes, regulations, and local ordinarim)applicable to and roan qage tanks. Name of tank owner(Pleas ii t): Signature of tank owner: Date: '`� 1� ' owner's Phone#: .71 NOTE: 1)Submit this completed form to the Local Agency(NOT the State Water Resources Control Board) By January 1,2009.The local agency list is available at: www_waterboards.ca-gov/usttoontads/cups agys.htmL 2)Notify the Local Agency of any changes to this information within 30 Days of the change. i TOTAL P.03