Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank(t3 ): „e'z'ator <br /> and Understanding of and Compliance with UST Requirements <br /> d 4 <br /> Facility Naxoe: IFacility ll�#: <br /> Facility Add�ss: f-lrtbltl W I Reason for Subm- Form k One) <br /> Change o for <br /> Facility Phone 0 X Update Cerhfica <br /> Designated UST QRerator(s)for this Facility <br /> pltYiWlal.RY <br /> Designated Operator's Name:Karen R1113Caniz Relation to UST Facility(Check One) <br /> Businew Naive(If differeht from abmle): ❑ Oder 0 Operator ❑ Funployee <br /> Designated Operator's Phone#:(209)51$-4836 ❑ Service Technician X Third Party <br /> internationai Code Council Ceitific ation#:8032295-'UC Expiration.Date:06/11/2013 <br /> ALTERNATE I ftdimaO <br /> Designated Ope atoes Name: Relation to UST Facility(Check One) <br /> l3usiness Name(Ifdiffer ent froyn above), ❑ Owner ❑ Operator ❑ Bmployee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Tbird-P&rty <br /> #International Code Council Certification#: ]Expiration late: <br /> ALTERNATE.2 (Optional) <br /> Designate Operator's Nate: Relation to UST Facility(Check One) <br /> Business Name(if d=;,f"erew from above): 0 Owner ❑ Operator ❑ Employee <br /> Designawd Operator's?'hone W. 0 Service Technician ❑ Third-Party <br /> Jntemational Code Council Certification#: Expiration Date: <br /> I certify that, for the facility indicated at the top of this page,the individ W(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,i>ta 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 wndelr��nd s rage . <br /> NAME OF TANK OWNER(Please Print). P2 LA-01(�j <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWN'ER'S PRONE <br /> NOTE:1)SX 33MIT THIS COMPLETED FORM TO THE LOCAL.AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY X,2005.THE LOCAL AGENCY. LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/tist/contacWcup8 aa* -, t 1. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITEUN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> 100 'd �I tLLH oZ I 'ON XV9 193IJ MOM 0119Ad Wd OZ :ZO M/I 1 OULZ/Iff <br />