Laserfiche WebLink
Feb, 12. 2007 2:22PM °1 t Star Environmental, Inc. No. 5506 P. 4/4 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with LUST Requirements <br />Facility Name: Stockton Arca Office Facility ID 9: <br />Facility Address: 3330 N. Ad Art Road Reason for Submitting di is Form (Check One) <br />Stockton, CA 95215 r1l Change of Designated Opetator <br />Facility Phone #: 209-943-8666 ❑ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />V' C hJ 1-i/i` i'1 <br />Designated Operator's Name: JASON FSQUF:DA <br />Relation to US"I' Facility (Check One) <br />❑ Owner OperaLor ❑ Employee <br />L3 Sc I cc <br />Business Name Q(different from above): West Star Environmental, INC <br />�_,..... <br />Designated Operator's Phone #: 559-277-9373 <br />International Code Council Certification 4: 5246320-11C: <br />Expiration Date: <br />ALTERNATE I Wadanah <br />Designated Operator's Namc: NICK ADAMITL <br />Relation to UST Facility (Check One) <br />❑ Owner Operawr ❑ Employee <br />Business Name (/f different from above); West Star Environmental, Inc <br />Designated Operator's Phone #: SW277-9378 <br />International Code Council Ccrtificetion #: 5246325 -VC <br />Expiration Date: <br />ALTERNAT192 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Scrvice Technician ❑ Third -Party <br />Expiration Date: Y <br />RLninesc Name (/fdifferentfrom above); _ <br />Designated Operator's Phone #: <br />international Code Council Ccrtification #: <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) - (f). <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 TAMC OWNER (Please Print)- 1 �s <br />SIGNATURE OF TANK OWNER: <br />DATE: r' O'WNER'S PHONE, #: �L L w— <br />NOTE: 1) SUBMIT TIES COMPLETED FORM TO THE LOCAL AGENCY (NOT TIME STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca ov/ust/cnntacts' a s.html. <br />2) NOTIFY THE .LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />