COMPLIANCE INFO_2010-2015 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Uniclocs Niernber Agencies or where approved by yortr Local Jurisdiction Authority Cited: Title 23, Div, 3, Cb. 16 California Code of Regulations (CCR) FACILITY NAME FACILITY PHONE Flyers #487 ( ) NA FACILITY SITE ADDRESS CITY 983 Moffat Blvd Manteca REASON FOR SUBMITTING THIS FORM (Check One): Change of Designated Operator ❑ Update of ICC Certification Expiration Date(s) UT?TATAT?V DESIGNATED IIST nPRRATOi2 FOR THIS FACTI.ITY DESIGNATFD OPERATOR NAME: Jacob Lyon RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Jfdifferentfromabove): LG Environmental DESIGNATED OPERATOR PHONE: (530) 513_7828 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8052304 -UC EXPIRATION DATE: 61212012 Ar' YMNATR i DESIGNATED TI.ST OPERATOR FOR THIS FACILITY(Outiona/) DESIGNATED OPERATOR NAME: Clent Gagnler RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAt IE (lfdiffererrt from above): LG Environmental DESIGNATED OPERATOR PRONE: (630) 521-6818 ext. INTERNATIONAL. CODE. COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 9/2912012 AI 'rRT2NATZ<. 2 DESIGNATED UST OPERATOR FOR THIS FACILITY Notional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (Jfdii ferentfr�mn above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.. EXPIRATION DATE: A 1.TRRNATR 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Ovtionat) DESIGNATED OPERATOR NAME: RELA'T'ION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party I3USINFSS NAME (tfdiiferentfrarn above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL, CODE COUNCIL CERTIFICATION NO.: EXPIRATION DA'Z'E: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operatoi•(s). The individuals) will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations, Title 23, Section 27I5(c) through (f), Furthermore, I understand and am In compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANK OMINER NAME: Amanda Appelt TANK ONVINER TITLE: Environmental Manager ONVNER PHONE: 530 885-0401 TANK OWNER SIGNATURE: DATE: May 16, 2012 INSTRUCTIONS 1. Report the natne(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available on-line at: ivFvw.fecsafe,org/e/certsearch.11tml. 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: w�vw.ul►idoes.org/members/whoregtilateswhat.littnl. Contact information for other local agencies within California is available at: www.swreb.ca.govlcivphotiie/tist/contacts/(Iocs/local_agenc), list.xls. 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. U\-062 -1/1 wwIv.110(loes.org 09/22/05