Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Rancho Sart Miguel Facility ID#: <br /> Facility Address: 1427 S Airport Way Reason for Submitting this Form(Check One) <br /> Stockton Calif. X Change of Designated Operator <br /> Facility Phone A(209)942-2840 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Daren R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(1fdIerent fenny above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone It,(209)518-4836 ❑ Service Technician X Third-Party <br /> international Code Council Certification#:5266643-UC Expiration Date:07/16/09 <br /> ALTERNATE 1 O Ronal <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name: <br /> Business Name(Ifdje)entfionrabove): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: [3Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> ' Relation to UST Facility(Check One) <br /> Designated Operators Name: <br /> Business Name(lfdlifferentfi-om above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#.' ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> I certify that, for the facility indicated at the top of this page,the individual(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, in 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 underground stor ks. <br /> NAME OF TANK OWNER(Please Print :Gilbert Silva <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 05/01/08 OWNER'S PHONE#: (209)858-U 101 Ext.319 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www wateiboards ca eov/ustleontacts/cuoa agvs.htal <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />