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07 17:11 9163752944 CHP FACILITIES jry4,2/05 <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br />.For use by Undoes Member Agencies or where approved by your Local Jurisdiction <br />Authority Cited- Title 23, Div. 3, Ch, 16 California Code of Regulations (CCR) <br />FACILITY NAME <br />FACTL'ETY S� ADDRESS <br />REASON FOR SU8MITTING THIS FORM (Check One); C&Changc of Designated Operator <br />PRIMARY DESIGNATED UST OPERATOR FOR <br />DESIGNATED OPERATOR NAME: / ex 14z)eft <br />BUSINESS NAME (tfdi,�erenrfromabove): -- <br />DESIGN AT1F D OPERATOR PHONE: <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.; <br />AL'I'>CRNATE 1 DESIGNATED UST OPERATOR FOR THIS <br />DEW,NATED OPERATOR NAME, <br />BUSINESS NAME (If dri femnr from above); % <br />DESIGNATED OPERATOR PHONE: ) �7 <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO,; <br />PHONE <br />Update of iCC Certification Expiration Date(s) <br />RELATION TO UST FACILiTTY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />ext Service Technician ❑ Third -Party <br />EXPIRATION DATE; fj <br />�-� RF,LATiON TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />ext Scrvice Technician ❑ Third -Party <br />EXPIRATION DATE: �j n3jy�r�C J <br />ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY <br />DESIGNATED OPERATOR NAME; <br />BUSINESS NAME (If different from above): <br />DESIGNATED OPERATOR PHONE; { ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: <br />ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS ]FACILITY <br />DESIGNATED OPERATOR NAME; <br />BUSINESS NAME (Ifdi,(ferem from above): <br />DESIGNATED OPERATOR PRONE: ) ext. <br />INTERNATIONAL COUP; COUNCIL CERTIFiCATION NO.; <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Tcohnician ❑ Third -Party <br />EXPIRATION DATE: <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Scrviee Technician ❑ Third -Party <br />EXPIRATION DATE; <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br />Operator(s). The individuals) will conduct and document monthly facility inspections and annual facility employee training <br />in accordance with California Code of Regulations, Title 23, Section 2715(c) through (f). Furthermore, I understand and am <br />in compliance with the requirements (statutes, regulations, and local ordinances) a plicable to underground storage tanks. <br />TA O'WNiER�AME: <br />TnN OwIvER TITLE: �4WNER 1400NE: <br />iNSTRUCTION�S <br />i. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (iCC). iCC certification <br />information is available on-line at: wwvv.iccsafe.org/c/c"earch.htmi. Search for "California UST System Operators_" <br />2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and <br />contact information are listed on-line at: www.unidoes.org/members/WhGregulateswhat.btml. Contact information for other <br />local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs/local—agency_1ist.xls. <br />3. 23 CCR §2715(a) requires that you notify the local agency of any changes to this information within 30 days of the date of change. <br />VN -062.1/1 www.voldoci.org 0/22/05 <br />