Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: ft&n Facility ID#: t 01 <br /> Facility Address: ZD Reason for Submitting this Form(Check One) <br /> L-05>1 C,5) Ci S -.I-k8 9) Change of'Dcsignated Operator <br /> Facility Phone#: 2&)- -�Mq — 0155 0 Update Certificate['Apiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Nat Relation to UST Facility(Check OneJ <br /> Business Name Qfdifferenlftom above): <br /> 0 Owner 0 Operator 0 E'niployee <br /> Designated Operator's Phone -3 91 Service`technician F1 Third-Part�- <br /> International Code Council Certification Expiration Date: <br /> At:rERNA,rE I (Optional) <br /> Designated Operator's Name: Relation to UST facility(Check Oyie) <br /> Business Name(If dif D Owner 0 Operator 0 Employee <br /> Lferentftom above): <br /> Designated Operator's Phone#: 0 Service"Technician 0 Third-Party <br /> International Code Council Certification 4: Expiration Date: <br /> A 1;1'fRNA:I*E 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dfferenlftom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone 9: 0 Service Technician 0 Third-Part), <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)-(t). <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): t-0) <br /> SIGNATURE OF TANK OWNER: <br /> DATE: l <br /> I fit OWNER'S PHONE <br /> NOTE: 1)SUBMITTI-IIS 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: agyvsjltoll. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />