Laserfiche WebLink
!Ce& <br />Dec��o <br />F ©o <br />' 06' <br />Owner Statements of Designated Underground Storage Tank (IAS W <br />A <br />L <br />and Understanding of and Compliance with UST Requirements` F,91 jS(TN <br />FacilityName: ("e , ' FL G kA-NjE . j 1/ i C4: -F ► tw,t <br />FacilityID #: <br />Facility Address: C/ GP 0 1 � �� �`� t� 1=- <br />Reason for Submitting this Form (Check One) <br />y <br />I...i+ b i , 6 2 L <br />4 Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: z0 1 •— ?�46 •-- L' <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator';; .lame: ,., I 4P- �`,� ? l'y"s rt, C:ty <br />Relation to UST Facility Check Orae � <br />( ) <br />❑ Owner ❑ Operator ❑ Employee <br />Service Technician ❑ Third -Party <br />Business Name (Ifdifferent from above): A f f a rLi a _ --re g <br />Designated Operator's Phone #: ( 209) r7," Q (•I Z <br />International Code Council Certification #: , 5 2 y q ►t" ,.-0 U G <br />Expiration Date: �'�, Oh 1%,' <br />ALTERNATE 1 (Optionat) <br />Designated Operator's Name: -ZA Nt" A,, 1A 'PAM 01 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />)K Service Technician ❑ Third -Party <br />Business Name (If dierent from above):\ <br />Designated Operator's Phone #: 7-Ocl —7'y y _ a ( -2). <br />Intemational Code Council Certification #: ��C�d��J _G <br />Expiration Date: Q <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: PcV N <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑Employee <br />V Service Technician ❑ Third -Party <br />Business Name (If different from above): w & <br />Designated Operator's Phone #: -ZQ <br />International Code Council Certification #: 5ae, <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I certify that, for the facility irdirated 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). I ' <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): • �.� �4 �*S� i\ <br />SIGNATURE OF TANK OWNER: Ak 4A <br />r <br />DATE: ! /d Co OWNER'S PHONE #: <br />November 2004 <br />