Laserfiche WebLink
0 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Pac Bell dba AT&T California Facility ID#: SKTNCA01 <br /> Facility Address: 345 N.San Joaquin St Reason for Submitting this Form(Check One) <br /> Stockton O Change of Designated Operator <br /> Facility Phone#: (209)943-4128 0 Update Certificate Expiration Date <br /> Designated UST 011erator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: George Koffel Relation to UST Facility(Check One) <br /> Business Name(If different from above): Tait Environmental Services 0 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714.560.8200 O Service Technician 0 Third-Party <br /> International Code Council Certification#: 5247982-UC Expiration Date: 12/19/2008 <br /> ALTERNATE i(O tional <br /> Designated Operator's Name: Tait Environmental Services Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: See Attached 0 Service Technician 0 Third-Parry <br /> International Code Council Certification#: See Attached Expiration Date: See Attached <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> I certify that, for the facility indicated 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). <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)• Julle Khdryan <br /> r <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/18/2006 O ER'S PHONE#: 214-464-2599 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.gov/ust/contacts/cupa agys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />