Laserfiche WebLink
08/27/2009 12' a. 209466951Q VALL'Y ARCO PAGE 01/02 <br /> FAQ 43 33 <br /> G2 � 2 <br /> Owne3r`, r , <br /> A� S°C tements of Designated ou d Storage Tank(UST) Operator� <br /> � .,_ gn Undergrout <br /> and Understanding of and Complin-nc with I JST Requirements <br /> Facility Name: rC� Y�L t. $SRV<Cc` i�*i[oi"[) Facility In#: <br /> Facility Address: ' a✓L� Reason for Submitting this Form(Check One) <br /> Change of Designated Operator <br /> Facility Phone# I X updato Certificate Expiration Date <br /> Designated UST Operator(15)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Ar raiz Relation io 1 TCT Facility(Check One,) <br /> Business Name(If different from abcvE)- ❑ Owner d Operator O Employee <br /> Designated Qperator's Phone 9,(209)5184836 ❑ Scrvicc Technirian X Third-Party <br /> international Code Council Certification#:8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATE 1 tions[ <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name_ <br /> Business Name(Ifdlfferentfromabuve). ❑ Owncr ❑ Operator C3 Tmployee <br /> Designated Operator's Phone 4: ❑ Servicc Technician EI Third-Party <br /> ##international Codc Council Certification 4: � I Expiration Datc: <br /> ALTERNATE 2 (Optional) <br /> DC5lgrlateci Oy;;Iatur'S:`lainc: <br /> RP.latinn to TTST Facility(Check One) <br /> Business Namc(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's phone#: ❑ Service Tcehnician n Third-Parry <br /> International Code Council Certification#: Expiration Date: <br /> f <br /> I crrlify that, for the facility indicated at the top of thisage, the individltal(s) listed above will <br /> serve as Designated UST Operator(s). The individual( will conduct and document monthly <br /> facility inspections and annual facility employee trainir k. in accordance with California Code of <br /> Regulations,title 23, section 2715(c)- (�- <br /> Furthermore,I understand and am in compliance NV Ith the requirements (statutes, <br /> regulations, and local ordinances)applicable to and (ground storage taulks. <br /> NAME OF TANK OWNER(Please Print): 6 R i�1Q-M CyRtvs <br /> SIGNATURE OF TANK OWNER: <br /> DATE:ALO l OWNER'S PHONE 4. <br /> NOTE: I)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTRnt,BOARD)BY JANUARY 1.,2005. HE LOCAL AGENCY LIST IS AVAILABLE <br /> r� AT: www.waterboardS.ca.�o�'lust%runtacts/cU0a �v-1j, m . <br /> 2)N(YrOY TD-E, LOCAL AGENCY OF ANY CHANCES TI THIS INFORMATION WITHIN 30 DAY'S <br /> OF THE CHANGE, <br /> November 2(104 <br />