COMPLIANCE INFO_2006-2012 - Laserfiche WebLink

Home Browse Search

*RIECAVE DD MAY 0 7 2008 ENVIRONMEN'r HEALTH PEAMMSERVICES Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements —t 824 — — Facility Name: o net0MOM 0) _ Facility ID#: Facility Address:,;ILJ-WGC7&Wb0-A+0-4_-U3DLL I Reason for Submitting this Form(Check One) be 1_537(pX Change of Designated Operator Facility Phone#- C201 k3o -ME 0 It Update Certificate Expiration Date Designated UST Oaerator(s)for this Facility PRIMARY Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If differentfrom above):fQe_LjC&(,e jteS 13 Owner 0 Operator 11 Employee Designated Operator's Phone#: CI — 10C)LI - q,3,3(o 0 Service Technician ?( Third-Party International Code Council Certification#: 501XS4S1_f 0 0 Cz Expiration Date: / __q ALTERNATE I llqptionao Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If different from above): 0 Owner D Operator 0 Employee Designated Operator's Phone#: 0 Service Technician 0 Third-Party International Code Council Certification#: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If different from above): 0 Owner 0 Operator 0 Employee Designated Operator's Phone#: 0 Service Technician 0 Third-Party 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 individuals)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 SIGNATURE OF TANK OWNER: DATE: L, ---e, OWNER'S PHONE#: 131,rc - &7 '7 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.