COMPLIANCE INFO_2004-2012 - Laserfiche WebLink

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Dec 29 04 05:01p Alex 92dib551-7892 P.5 9 % Ownr,-r Stat Tre-, t!—,of - 1, 0 1 Facility 4 Facility ID k Facility Address 77 /v.5/")-/- Reason for submitting this Form (Check One) 0 Change of Desigm&od Operator 0 Update Certificate Date racility Phonc#. G9 Designated UST 0Mmj2ffjs for this Engyy �Ml Designated Operator's Name: A/AX- Relation to UST Facility (Check One) 1 0 Owner 0 Operator E3 Employee 0 Service Technician 9'4hW-Party Business Name (If&fferentfrom above):,9,#.4j,,$ 9E &110 Designated Operator's Phone#: _.3 1 ' International Code Council Certification #: tExpiration Date: _ -off W r Ivli 0 ZfLr-" tri Designated Operator's Name: Relation to UST Facility (Check One) 13 Owner 13 Operator 0 Employee 0 Service Technician C3 Third -Patty Business Name (Ydifferenifrom above): Designated Operator's Phone *: - L!!!!Tatio.d,Codc Council Certification fi: Expiration per: ALTERNATE 2 ffindynal) Designated Operator's Name: Relation to UST Facility (Check One) E3 Owner 0 Operator El Employee 0 Service Technician 0 Third -Party Business Name Qfdffierenifrom above): Designated Operator's Phone #: b9amational Code Council Certification #: Expiration Date: NOTE: THE LOCAL REGGLATORVAGENCY MUST BE NOTIRED OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. 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) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulation% and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER OR OWNER'S AGENT (Please Print): 2.4 R'4 LL -'T/ T SIGNATURE OF TANK OWNER OR OWNER'S AGENT: DATE: OWNER'S PHONE #: 4969 - ZI 3 C1Cj 7r Sep rnber 2004