Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Lathrop Gas and Food FacBity ID#: <br /> Facility Address: Reason for submitting this Form(Check One) <br /> 14800 W.Frontage Rd,Manteca,CA 95336 <br /> X Change of Designated operator <br /> FacilityPhone C 209L-239-2717 Update Certificate Expiration pate <br /> Designated UST Ooerator(sl for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Alex Jabbari Relation to UST Facility(Check One) <br /> Business Name(If&fferemrfiner abate):Norcal Pebokim Ser"We Ips ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 725-389-1262 X service Ta}mieian ❑ Third-Party <br /> International Code Council Certification#:5243897-UC Expiration Date:10/02R012 <br /> ALTERNATE <br /> Designated Operator's Name: Relation to UST Facility(Check Are) <br /> Business Name(Ijdijjerenr from-bone): <br /> ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Parry <br /> [ntemational Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opdm&g <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdijfemnr from-born)- <br /> ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council CertiScffion#: <br /> 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 ming 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 storage tanks. <br /> NAME OF TANK OWNER(Please Print): jq <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE (909 . a <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE FOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST 1S AVAILABLE <br /> AT:www.waterboardsxa.-ov/ust/contacts/cu s.html. <br /> November 2004 <br />