COMPLIANCE INFO_2009-2010 - Laserfiche WebLink

Home Browse Search

'Apr 05 10 08:40a Ahp.2 0 IF Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of Compliance with. UST Requirements Designated UST Ouerator(s) for this Facia' Facility Name: Waterloo Liquors Facility ID #: Facility Address: 2512 Waterloo Reason for Submitting this Form (Check One) Stockton, CA O Change of Designated Operator Facility Phone (559) ❑ 'Update Certificate Expiration Date PRIMARY Designated Operator's Name: Tony MttCC}1 Relation to UST Facility (Check One) Business Name (Jf difierent from above): Franzen -Hill Inc. i7 Owner ❑ Operator 0 Employee Designated Operator's Phone n: (5 59) 688-2977 X Service Technician X Third -Parry International Code Council Certification #: 8008380 -UC I Expiration Date: 2/25/2011 Designated Operator's Name: Terry Hodson Relation to UST Facility (Check One) Business Name (1f different from above):Frareeen-Hili O Owner a Operator ❑ Employee Designated Operator's Phone #: (559)688-2977 X Service Technician XThird-Party International Code Council Certification #: 8021463 -UC Expiration Date: AL'T'ERNATE 2 (uptaor ) Designated Operator's Name: Business Name (If dierent from above): Designated Operator's Phone #: International Code Council Certification#: Relation to UST Facility (Check One) ❑ Owner O Operator ❑ Employee ❑Service Technician ❑Third -Party 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) - (fl. 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): ��,► �r t -/7 SIGNATURE OF TANK OWNER: DATE:OWNER'S PHONE NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY I, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/ctipa aQvs.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004