BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

UNDEROUND STORAGE TANK S. ,STEM OWNER STATEMENTS OF DESIGNATED UST OPE AND UNDERSTANDING OF AND COMPLIANCE WITH UST4HE@&kAW For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited.• Title 23,Div. 3, Ch. 16 California Code of Regulations(CC%AR 2 9 2013 FACILITY NAME FACILITY PHONE WEST VALLEY AUTO SPA, INC. (209) 836-3464ENVIRON MENTAL FACILITY SITE ADDRESS CITY HEALTH nF:pA.RT1.. 2615 W. GRANT LINE ROAD TRACY, CA 95304 REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator E Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: ROBERT BARNHART RELATION TO UST FACILITY(Check One) BUSINESS NAME(If differenrfromabove): RELIABLE PETROLEUM INC. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (209)604-9336 ext. ® Vice Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: '55252540-U C EXPIRATION DATE: 1/28/2014 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(O tiona4 DESIGNATED OPERATOR NAME: LUPE SANCH EZ RELATION TO UST FACILITY(Check One) BUSINESS NAME(If differentfromabove): RELIABLE PETROLEUM INC. ❑ owner ❑ operator ❑ Employee DESIGNATED OPERATOR PHONE: (209)604-9363 ext. 845-8586 N Vice Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5250451-UC EXPIRATION DATE: FEB 9, 2015 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(OpdonaO DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(OpdonaO DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 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)through (f). Furthermore, I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAW: WEST VALLEY AUTO SPA, INC. / STEVEN JAY MUTNICK TANK OWNER TITLE: PRESIDENT OWNER PHONE: (408) 836-3698 TANK OWNER SIGNATURE: DATE: 29 MARCH 2013 INSTRUCTIONS 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council (ICC). ICC certification information is available on-line at:www.icesafe.org/eleeriscarch.htmi. Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.als. 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062-1/1 www.untdocs.ora 09/22/05