COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Facility ID#: Facility Address: Reason for Submitting this Form(Check One) ❑ Change of Designated Operator Facility Phone#: ❑ Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: ALTERNATE 1(Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED 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, regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER OR OWNER'S AGENT(Please Print): SIGNATURE OF TANK OWNER OR OWNER'S AGENT: DATE: OWNER'S PHONE#: September 2004