Laserfiche WebLink
Jul 14 05 01:50V <br />Jul 14 OS 11:26& <br />USTanx <br />L enx <br />5302683330 <br />53026-330 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: zAj Facility ID 4 ; Off/ <br />Facithy Address: Reason for Submitting this Form (Check owe) <br />(e Change of Designated Operator i <br />�F aul,ty phone it 12^4 -Z u9— E)" t �� Update Car6ricate Expiration Date <br />t 9 S� 4 Z' <br />L.� � / Designated UST Operator(s) for this Faeltity <br />PRIFA .m r <br />Designated Doeratdr's Name: JANINE KIRBY <br />Business Name (If different from above); USTanx <br />Designated Operabrs Phone ;x : (53U) 2iih-.39dii <br />ALTERNATE I fontronari <br />Relaron to UST Facility (Check ono) <br />D Owner 0 Employee 0 Service Tecnnkian <br />U Operator iii Thud Farcy <br />Fv�i rnlinn ri t— 1 nfn7i7nne, <br />Designated operatoes rmrnat RAN DALL KIRBY <br />Rttation to UST Faclltty (Chock one) <br />0 Owner 0 Employee 0 Service Technician <br />O Operator >t Third Party <br />(=xpiration Date: 12/28/2006 <br />Business Noma pratterent from above). UJ -f anx <br />Desioneted Oneratars Phone : (530) z68-3948 <br />International Code Council Certirlcstion u , 5250566 -UC <br />- t r <br />Daslgnated Operator's Name: TERESA KIRBY Rotation to LIST Facility (Check Otte) <br />Business Nome. (It different from above): USTanx 0 owner 0 Emp"a, 0 Service Technician <br />Des.gnatec Oparetcr s :✓none I;: (5:x0) Ldt7 984CA} L; operator i Third Party <br />INllrnafWl7t r'.AfiR crw lnnil CP.nIfICAtiDn ri: SZ�.n/7-UC Expiration Date: 10123/21306 _ <br />ALTERNATE 3 (Opttonon <br />Deoignatod Operator's Namo; Rotation to UST Facility (Chock ono) <br />Bu6in866 Name (IF different from above): 0 Owner 0 Employee 0 Service Tachnician <br />Designated Operators Phone k : 0 Operator 0 Third Party <br />Irtl,rnational Code Council Certificallon d: EXpuetrDn Date: <br />:'iiTl-liN 3C Di.Y3 OF THE CHAN,C. <br />I certify that, for the facility Indicated at the top of this page, 'he individual(s) listed above will <br />serve as Designated LIST Operaiw(s), l he individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, tille 23, section 7715 (c) - (f). <br />Furthermore, I understand and am In compliance with the requirements (statutes, <br />reguations, ss nw iacial orciirtan;wr:;} apput:aiuif. to ui rkuetuiourid s orage Lanka. <br />NAML UIL IANK UWNER ! _ C <br />OR OWNER'S AGENT (Please Print) : -- /V42 1-1 /� J ' ^i—N <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: LL4 <br />0ATF: 1 0 OWNER'S PHONE # : � }�'� b97S <br />p.2 <br />P- 2 <br />