Laserfiche WebLink
03/12/2010 13:14 FAX 17074466192 TANK-TEK IM 002/004 <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br />For use by Unidocs Afmbsr Agencies or where approved by your Loa JwisaUdion <br />Authoriry Cited: Tyle 23, Div. 3, Ch 16 California Code of Regulations (CCR) <br />LrrY NAMe <br />CRLLC #2705446 <br />FACILITY SITZ' ADDRFss <br />1403 COUNTRY CLUB BLVD <br />REASON FOR SUBMITTING THIS FORM (Check arr)_ <br />PRIMARY DESIGNATED UST OPERATOR FOR <br />DESMNATRD OPERATOR NAME: Richard Thomas <br />9USINESS NAME WdWsm,gfi_ abow): Tank -Tek Enti <br />DESIGNATkD OPERATOR PHONE: (707) 446$151 <br />INTERNATIONAL CODE COUNCIL CURTIFICATION NO.: 525 <br />ALTERNATE 1 DESIGNATED UST OFEPUTOR P'OR <br />DESIGNATED OPERATOR NAME: <br />NANO (If diffatnifrmx above)= <br />CODE COUNCIL CERTIFICATION NO.: <br />FACUM HONE <br />209-943-2082 <br />CITY <br />STOCKTON <br />of Designated Operator Update of TCC Certification Expiration Date(s) <br />IS FACILITY <br />RELATION TO UST FACILI'T'Y (Check (bt) <br />nmentall Corp. ❑ Owner ❑ Operator ❑ Employee <br />ext. ❑ Service Technician ® Third -Party <br />MCI.110 EXPIRATION DATE: 1/2012011 <br />RF3..ATION TO UST FACILITY (Check One) <br />❑ Owna ❑ Operator ❑ Employee <br />els. ❑ Service Technician ❑ Third -Party <br />EXPIRATION DATE: <br />ALTERNATE 2 DESIGNATED UST OPE"TOR FOR THIS FACILITY <br />DESIGNATED OPERATOR NAME: <br />BUBWESS NAME Wd&nen ftorn abme): <br />DESIGNATED OPERATOR PHONE: <br />RNtr] NATIONAL CODE COUNCIL CER <br />nnq <br />ALTzRNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY <br />DESIGNATED OPERATOR NAME: <br />6USINESS NANM (jrtdi „i jroni above): <br />OPERATOR PHONE: <br />CODE COUNCIL CERTIFICATION <br />RELATION TO UST FACILITY (Chock OPW <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Pasty <br />EXPIRATION DAM <br />RELATION TO UST F'ACII JTY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />r"MATION DATE: <br />I certify that, for the facility indicated at the top of this page, the individuals) listed above will serve as Designated UST <br />Operator(s). The individuals) will conduct and document Monthly facility inspections and annual facility employee training <br />in accordance with California Code of Regulations, 'Title 23, Section 2715(e) through (f). Furthermore, I understand and am <br />in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. <br />TANK OWNERNANIE: CRLLC / Designee; Armen_ Mkrtychian <br />TANK OWNER TITLE: Comp 1 i anc e <br />OWNERPRON,E: ( 925 ) 884-0800 <br />TANK OWNER SIGNATURE: 111' � �_ DATE: ys e0.z2 <br />INSTRV ONS <br />1. Report the name(s) of the Designated UST Operators) as registerod with the International Code Council (ICC). ICC celtiEcation <br />informaticm is available on-line st: www.ieesafe.org/elcertm areb.btml. Search for "California UST System Opa utors_" <br />2. Submit this completed form to the local agency that regulates this facility"s USTs. Undoes member agency jurisdictions and <br />contact Wbrmation are listed on-line at www.vnldoc&org/members/whorepiateswbatbtml. Contact information for other <br />local agencies within California is available at www swreb.ea.gov/cwphomdust/coutnewdamnocal agent list.=Is. <br />3. 23 CCR §2715(4) requires that you Notify the local agency of any changes to this information within 30 4sys of the date of change. <br />UK.86= -1A www.unidnesA q WOOS <br />