Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Z Facility ID#: fA oc>j p p <br /> Facility Address: 50 v W. -T..rr%.v Reason for Submitting this Form(Check One) <br /> rj 3 Li a, -K Change of Designated Operator <br /> Facility Phone#: a�yc r 12(.oS ❑ Update Certificate Expiration Date <br /> Desianated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Roy t�T G��� Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): ❑ Owner ❑ Operator I<Employee <br /> Designated Operator's Phone P L——31 . 3 Lc, ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification boU c Expiration Date: <br /> ALTERNATE I p tional <br /> Designated Operator's Name: a. p Relation to UST Facility(Check One) <br /> Designated Operator's Phone#: J—U 9— ) L v ' C1 Service Technician ❑ Third-Parry <br /> International Code Council Certification#: 4,5 p Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from 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 storage tanks. <br /> NAME OF TANK OWNER(Please Print): 1 H p , <br /> SIGNATURE OF TANK OWNER: <br /> DATE: �-%3 -C)-) OWNER'S PHONE#: ��a• 1���- ���� <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.waterboards.ca.gov/ust/contacts/cQaa aeys.htm]. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />