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i Nape 'II UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITII UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by yore Local Jurisdiction Authority Cited: Title 23,Div i,Ch. 16 California Code of Regulations(CCR) I FACILITY NAME FACILITY PHONE-- FACILITY SITE ADDRESS CITY i i REASON FOR SUBMITTING 1I1IS FORM(Check One): UCbrargerifEiesignaled0perium U Update of ICC Cartification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATORNAME: - r. Rr1 Mpf RELATION TO UST FACILITY(Check One) BUSINESS NAME(7fdBeremfiom above): �Ovr1(Ery /DC�14 ,{J x El Owner EJOperator El Employee DESIGNATED OPERATOR PHONE: 2O1, ) $37_plo ext aty Service technician CW Ihird-Party j I INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: �10/C�/. /' � EXPIRATION DATE: Alerch 2 zo I ALTERNATE I DESIGNATED UST OPERATOR FOR THIS 4FACILITV(pintanan DPSIGNAT®OPERATOR NAME: �.�� RELATION TO UST FACII.ITY(Check One) BUSINESS NAME(ltdfferemf ee above): Zifc. � ❑ Owner [I Operator ❑ Employee oN/ec Pdm� lwny , DESIGNATED OPERATOR PHONE: y ex� ❑ Service Technician � Third-Party j INTERNATIONAL CODE COUNCIL CERTIFICATION NO: EXPIRATION DATE:,j-,,, _ _ 0 33 Jonc z/ 20/ ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY( ional) DESIGNATED OPERATORNAME: �u�j J�� s RELATION TOLIST FACILITY(Check One) BUSINESS NAME(lfdiffeenlfrom above): eN xn Cr El Owner Owner l_ Operator El Employee U-�C �uMD CilMp dy DESIGNATED OPERATORPHONE: ZO� ) Jr3 r� ' a pq Service Technician J'Ilriri-PmTy INTERNATIONAL CODE COUNCIL/:ERIIFICATIONNO: EXPIRATIONDATE: y �d fS- 0163 565 �nnr_a ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Oplona!) DESIGNATED OPERATORNAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(lfdiffererufrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Ihird-Party I INTERNATIONAL CODE COUNCIL CERTIFICATION NO: EXPIRATION DATE: I I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated OST Operator(s). The individuals)will conduct and document monthly facility inspections and annual facility employee training t in accordance with California Cade of Regulations,Title 23,Section 2715(c)through(D. Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANKOWNERNAME: i TANK OWNER TITLE: OWNER PHONE: ( ) TANK OWNER SIGNATURE: DATE:_ 1 INSTRUCTIONS I. Report the name(s)of the Designated UST Operium(s)as registered with the International Code Council(ICC).ICC certification information is available on-line at:wwwAcesafe.org/e/certsearch.h(ml.Search for"California UST System Operators" 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and I contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.html. Contact information for other � local agencies within California is available at:www.swreb.ca.gov/cwphome/ust/contacts/doe0oul-figencyjlstAls 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062-I/1 w .anidocs.org 09/22(05 i t j I