Laserfiche WebLink
Owner Statements oflesigmted Underground Storage T (UST) Operator <br /> and Understalading of and Compliance with UST Requirements <br /> Facility Name: Country Side Mini Mart FacitityID#: <br /> Facility Address: 14971 N. Hwy. 88 Reason for Submitting this Form(CheckOne) <br /> 4 Lodi, Ca.95240 ❑ Change of Designated Operator <br /> Facility Phone#: 209 388-5380 ❑ UpdatcCertificateExpiration Date <br /> Desigaated UST O tor(sl for this Facility <br /> PRIMARY <br /> Dcsiguated Operator's Name: Thomas Lee Hingstou E Relation to UST Facility(Check One) <br /> Business Nam @d0`'erenrfmmabove): C.E.S. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 707'87-4770 [3 Service Technician 19 Third-Party i <br /> International Code Council Certification 9: 5301063-UC Eatpiration Date: 12-12-2010 <br /> ALTFMNATE 1 <br /> Designated Operator's Name: Tam Hmgston Relation to UST Facility(Check Orte) <br /> Business Nam(If di ar-ent from above): CES ❑ Owner ❑ ❑ Employee <br /> Designated Operator's Phone ff: 707-987-4770 ❑ Service Technician ® Third-Party <br /> International Code Council Cerci&cation : 524377&UC ExpiraaionDrate: 01-18-2010 <br /> ALTERNATE 2 (Opdond) <br /> Designated Operator's Name: Relation to UST Facility(C3ceckOr4 <br /> Busir Nance(If Aftrentfrom above): ❑ Owner ❑ Operator ❑ Employee } <br /> DesignaW Operator's a k ❑ Service Tedm€clan ❑ Third-Party <br /> International Godo Council Certification A Expiratiat Date <br /> �. ALTERNATE3 <br /> DesiOperator's Name: Relation to UST Facility(Check One) <br /> Business Name(If&Jerenrfromabove). © Owner 0 Operator ❑ Employee <br /> Designated Operator's Drone#: ❑ Service Technician 0 Third-Party <br /> International Code Council Certification : Expiration Date: <br /> I certify that,for the facility indicated at the top of this page,the individuals) listed above will serve as <br /> Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in,accordance with California Code of Regulations, title 23,section <br /> 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and <br /> focal ordinances) applicable to underground storage tanks. <br /> NAM OF TANK OWNER a Print): 4r—P,91Gr y,)W1W& <br /> SIGNATURE OF TANK OWNER: <br /> s � <br /> DATE' Def OWNER'S PHONE#: �.y <br /> i <br /> 2)N MFY THE LOCAL AGENCY OF ANY CHANGES TO TEffi INFORMATION WMIN30 DFA.YS OF THE CHANGE <br /> Z,d <br />