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1 DESIGNATED UNDERGROUND STORAGE TANK OP a <br /> ����R <br /> NOTIFICATION FORM <br /> For use by Unidocs Member Agencies or where approved by your Local JurisdictiM nN�� '�'Tr'�L Hq TH <br /> Authori Cited:Title 13 Cal'ornia Code o Re lations§2715(a) _ _ I" <br /> A <br /> - <br /> A PDF copy of this completed form must be electronically submitted via either the California Envirofinental Reporting <br /> System(CERS)website or an equivalent local agency electronic reporting portal within 30 days of a change in ownership <br /> of the underground storage tank(s) or the addition of a new person performing Designated UST Operator monthly <br /> inspections and/or facility employee training at any facility covered by this notification. <br /> A. UST OWNER IDENTIFICATION <br /> U TOWNER NAME8 , _ UST OWNER PHONE NUMBER <br /> tS f �, O t ✓le f Q106'$01— �o3z. ext. IJ R <br /> UST 0 WNER CONTACT,N4 (If other than sole proprietor) UST OWNEF CONTACT TITLE(If other than sole proprietor) <br /> Vre C aFC''"6-6r)5 <br /> REASON FOR SUBMITTING THIS FORM(Check One) NOTIFICATION DATE(Date this form was prepared or last updated) <br /> ❑ Change of Designated UST Operator q <br /> ❑ Chane of UST Owner <br /> By electronically submitting a PDF copy of this form,the UST Owner certifies that,for the facility/facilities identified on this <br /> form and any additional pages in the PDF file upload,the indivMdual(s)listed on this form and any additional pages will serve <br /> as Designated UST Operator(s).The individual(s)will conduct and document monthly facility inspections and facility employee <br /> training in accordance with California Code of Re Mations Title 23 Section 2715(c)-ft <br /> B. FACILITY IDENTIFICATION <br /> FACILITY NAME <br /> i CERS ID or Facility ID <br /> SITE ADDRESS <br /> CITY ZIP CODE <br /> CA <br /> ® Check here if this notification covers multiple facilities and attach a list including Facility Names,Site Addresses,and CERS IDs. <br /> i C. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR(S) <br /> Designated UST Operators must have current"California UST System Operator"certification from the International Code Council <br /> i <br /> (ICC).Each facility must have at least one Desi ted UST Operator.ListinR alternate Desiggated UST Operators is a tional. <br /> PRIMARY DESIGNATED UST OPERATOR NAME ICC CERTIFICATION NUMBER PHONE NUMBER <br /> Kris Bell 5297793-UC (408)971-2445 ext, <br /> ALTERNATE l DESIGNATED UST OPERATOR <br /> NAME ICC CERTIFICATION NUMBER PHONE NUMBER <br /> Brian McPheeley 8394903-UC (408)971-2445 e7tt, <br /> ALTERNATE 2 DESIGNATED UST OPERATOR <br /> NAME ICC CERTIFICATION NUMBER PHONE NUMBER <br /> Mara Guamelli 8158671-UC (408)971-2445 ext, <br /> ALTERNATE 3 DESIGNATED UST OPERATOR <br /> NAME ICC CERTIFICATION NUMBER PHONE NUMBER <br /> Deborah Ward 8014655-UC (408)971-2445 ext, <br /> ALTERNATE 4 DESIGNATED UST OPERATOR ICC CERTIFICATION NUMBER PHONE NUNMER <br /> NAME <br /> Israel Santillan 8057571-UC (408)971-2445 ext <br /> ALTERNATE 5 DESIGNATED UST OPERATOR <br /> NAME ICC CERTIFICATION NUMBER PHONE NUMBER <br /> Steve Parmenter 5311561-UC (408)971-2445 ext. <br /> ALTERNATE 6 DESIGNATED UST OPERATOR <br /> NAME ICC CERTIFICATION NUMBER PHONE NUMBER <br /> Attach additional page(s)containing the above information if more alternates may be used <br /> UN-062 www.ur ldocsxrg III-Rev.01/04/16 <br />