COMPLIANCE INFO_2003-2011 - Laserfiche WebLink

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Owner Statements Designated Underground Storageqank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Country Side Mini Mart Facility ID #: Facility Address: 14971 N. Hwy. 88 Lodi, Ca. 95240 Reason for Submitting this Form (Check One) ❑ Change of Designated Operator ❑ Update Certificate Expiration Date Facility Phone #: (209) 368-5380 Designated UST Operators) for this Facility Designated Operator's Name: Thomas Lee Hingston II Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party Business Name (If different from above): C.E.S. Designated Operator's Phone #: 707-9874770 International Code Council Certification #: 5301063 -UC Expiration Date: 12/28/2008 ALTERNATE 1 (Optional) Designated Operator's Name: Business Name (If different from above): Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Designated Operator's Phone #: International Code Council Certification #: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: - Business Name (If dierent from above): Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Designated Operator's Phone #: International Code Council Certification #: Expiration Date: ALTERNATE 3 (Optional) Designated Operator's Name: Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Business Name (If differentfrom above): Designated Operator's Phone #: International Code Council Certification #: Expiration Date: I certify that, for the facility indicated at the top 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 accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please Print): —4y9AL i)k4o, Fe -Gid gr!, Ltd� SIGNATURE OF TANK OWNER: (Mefyfie,-� DATE: f 2 — / _ G 4- OWNER'S PHONE #: /2Q q) 57q -S7 —,;t Lj ej i.- 21 NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.