Laserfiche WebLink
JUL-06-2011 15:25 Service Station Systems 4,P ^938 8888 P.02 J$ <br /> -10 <br /> JUL 0 6 2011 <br /> t_*'7'T <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> F FadFity ID 0. 1361$7 <br /> Facility Addrt : 2375 W.Grant line Reason for SuWnftft this Form(Chack One) <br /> TrE ,CA 95376 S Change of DeslgnaW Operator <br /> FouNty P (2179)83fr-8908 o update Certificate axpiradon Date <br /> Designated UST s)for this Facility <br /> Prifrtary <br /> Designated Operators Nom' Dave Thomas Relation to UST FaciliWC-heck One) <br /> Business Name(NfI9r Nhorn )' ServiceSt"on Systems a owner 13 Operator 0 E=mployee <br /> Des4mged Operator's Phone ec 408 971-2445 M Service Technician M Thkd-Party <br /> t Code Council CartiOcatlon#: 525856641C Expiration Date' 7/2/12 <br /> Alternaft 1(Optks MO <br /> Designated Op~3 Name: Shane Flores fteiation to UST Fadlitl(Check One) <br /> again=Marne(N dffmnt from above): Service Station S tems la Owner ® OPerator t7 EMPIOYes <br /> Designated Operator's Phone# (498)-971-2446 is Service Technician Qj 'third-Party <br /> International Code Council CanWORtion# 5249001-UC Expiration Off' 4/5113 <br /> Aft-mate 2(Optional) <br /> Designated OperallCn's Name: Ryan Caggy Retation to UST Faciiih(Check One) <br /> Business Name(NdWbrant i3nm ): Service station Systems D Owner 13 aerator a Employee <br /> Designated Operator$Phone# 408 971-2445 is Service Tectwician la Third-Party <br /> l international code Council Certification a Expiration Date: / ) <br /> Tank Owner <br /> I car*that, for the facility indicated at the top of this page, the individual($)listed above will serve as Designated <br /> UST Operator(s). The indWual(s)will conduct and document monthly facility inspections and annual facility <br /> employee training, in accordance with Califomia Code of Regulations, We 23,section 2715(c)-(t)" <br /> Furthermore, I understand and am in compliance with the requirements otaWes, regulations,and local <br /> ordinances)applicable to Underground�sto�rage tanks. �� <br /> Name of tank owner(Please PM- 111111. <br /> Signature of tank owner.• <br /> Date: /ten �� _.. Ownoes Phone S: <br /> 1)Submit this completed form to the Local Agency(NOT the State Water Resources Control Board) <br /> By January 1,2005.The local agency list is available at. www"waterboards.ca.gov/ust/contacts/cups—agys.htmL <br /> 2)Notify the Local Agency of any changes to this Information within 30 Days of the change. <br />