Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: SBC Facility ID 4: TPACCAI I <br /> Facility Address: 10 E.12Th Street <br /> Reason for Submitting this Form(Check One) <br /> Tracy 0 Change of Designated Operator <br /> Facility Phone#: (209)943-4128 0 Update Certificate Expiration Date <br /> Desiggated.UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: George K Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 714.560.8200 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: 52479824JC Expiration Date.- 12123/2 <br /> ALTERNATE I(Opfianal) <br /> Designated Operator's Name: Tait Environmental Systems Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 714.560.8200 0 Service Technician 0 Third-Party <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 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> I certift,that.for the facility indicated at the top of this page,the individual(s)listed above twill <br /> serve as Designated UST Operator(s). The individual(s)N-611 conduct and document monthly <br /> facilit-y-inspections and annual facility employee training,in accordance Axith 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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <br /> > <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STA *ATEjj <br /> 0,5. THE LOCAL AGENCY LIST ISA BLE <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,20 <br /> AT:xvxN­.v.waterboaLds ca_goy/ust/contacts/cupa_aZys htinL <br /> _0 <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN J$IVS <br /> OF THE CHANGE. 3:>C <br /> -4 <br /> Not&embec2000 <br />