COMPLIANCE INFO_1996 - 2004 - Laserfiche WebLink

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Owner Statements -,'Designated Underground Storage, Wank (UST) Operator and Understanding of and Compliance with UST Requirements facility Name: t-L - --- - �( Facility ID#: Facility Address--7 �� (VI .tJ.gyp 7 L4-f" C U.IZ ?- Rte"fbSubmitting this Form(Check 1 One) � - �� Change of Designated Operator 0 pdate Certifigtc Expiration Date _ Facili 7- - v Designated UST Operator(s)for this Facility PRIMARY — - - -- -- --� Desi ted Operator's Name: �..O K.1 r 1�t;S H d ld i4 _I Relation to UST Facilites Check Ong Business Name(If difereni from above): ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician 19 Third-Party - - _ Designated Operator's Phone#: ct I t, - 8 2 V I $ International Code Council Certification#: _a SZ2,a a Ll C. _—_Ex iratim n Date: -ti - -- - ALTERNATE 1 tkrral Designated Operator's Name: - _ - - i Relation to UST Facility Check One Business Name(If differentfrom above): ❑ Owner ❑ Operator ❑ Employee 1 _. ❑ Service Technician ❑ Third-Party- Designated Operator's Phone#: International Code Council Certification€t: _ _ Expiration Date: ALTERNATE 2 clonal Designated Operator's Name: -___-Relation to UST Facility 6___ One) Business Name(Ifdigerent from above): ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician -❑ Third-Parry_--_-- Designatod Operator's Phone#: International Code Council Certification#: Expiration Date_ {{ - -- ------ - - -- - - - --- -_—J I certify that, for the facility indicated at the top of this page,the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (0. Furthermore, I understand and am in compliance with the requirements(statutes, regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER(Please P SIGNATURE OF TANK OWNER: DATE: °�y�D L), OWNER'S PHONE#: 'La q '01 J -7 4 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/usticontacts/cups asys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.