Laserfiche WebLink
AUG/07%2009/FRI 07. 05 All FOOD FOR LESS WH. FAX No, 12098580108 P. 002 <br /> 09/09/2009 20:51 2999875 KAREN ARNAIZ PAGE 02/67 <br /> oomehr Statements of Des>gate&Undergxoun.d Storage Tank(USI)-Operator <br /> and Uaderstending of and Compliance with UST Requirements <br /> Faoy�iryName: ge facility ID#: <br /> Facility Address: t,l3C� /f�ayt-{},� Reason faT submitbg this form(Cheek One) <br /> Change of Designatc d O,peraor <br /> Fao9llty Phone# X update C:e1tifiQW 1✓*t80"bete <br /> Desiatnated UST Uparatorfs)for this Faculty <br /> P�r�x <br /> Designated 0peratm13 Na v Karen R Arnaiz Ro)aflon to UST Facility(Check Ow) <br /> A,xsiuess iVatue(rfdoyentftom obave): ❑ Owner 0 Operstor d Employee <br /> Designated Operator's Phome# 209 518-4836 ❑ Sen ice Technician X hitd pam <br /> ho mationa)Code C,outtoif Certification 9:8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATI'L 1 (O"!!9 <br /> msignatrd Operator's.Name• Relation to UST Fsa iiy(Check One) <br /> SusincssName(Ydifsrentfromabave): ❑ Owner ❑ Operator ❑ Employee <br /> t)"j xed Operator's Phone#: ❑ Service.Tcdmieiau n TbirdrPuty <br /> #Int-II ondl Code Council CcAwcation Expiration DM; <br /> Das�p=ed Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different front above): ❑ Owntr O Operator 0 Euiployee <br /> Designated Opcmtoes Phono#: o Service Technician ❑ nw-Parry <br /> Intomadonal Code Council Carficatioo# E?tpuatioaDate: <br /> I oertify that,for the facility indicated at the-top of this page,the iuutdiYid ial(s)listed above will <br /> serve as Designated UST Operator(s). The ixldividual(s)will conduct and doc=ent MotatWY <br /> facility inspeedow and annual facility employee training,in accordance with California Code of <br /> Regulations,title23, secdon:2715(c)-(f). <br /> Furthermore,I understand.and am in compliance with the requirements (statutes, <br /> regulations,and local o)rdimmees):applicable to underground storage tauks. <br /> NAW OF TANK OWNER(Please Print), —C <br /> SIGNATUREOFTANK OWNER:/ �f <br /> DATE: LN OWNER'S PHONE 'NOTE.1)SUBMIT TIES COVETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)OY JANUARY 1,2005.THE LOCAL AGENCY LXST IS,A.'VAJLAULE <br /> AT:w,ww-tvaterhaar�,gov/1sticoneacts:cuUa2ys hnn,. <br /> 2)NOTIFY I E LOCAL AGENCY OF ANX CWGXS TO.TWS INFORMATION WrrB IN 30 DAYS <br /> OF TJ37 C7tI,ANGE. <br /> November 2004 <br />