Laserfiche WebLink
Ma !an 20 06 08:46a Alex JahDari 1925517852 p2 <br /> ovvmer Statements of Designated Underground Storage Tank(UST)Operator <br /> and understanding of and Compliance With UST Requirements <br /> Facility l`iarne: (r�.y} e x.71-�+�f� _ ? Facility rD#: <br /> Facility Address: Reason for Suh-nitting this Form!Check One)J� <br /> OK Change of Uesignat:ed Operator <br /> Facility Phone ii �) V 3A�e ❑ Update Certifecaw L--Xpiration Date <br /> Designated UST OpErator(s)for this Facilitl <br /> PMEWARY <br /> Designated OpeMW%Name: Me e RR.iation to USI'Facility XhecKOne} <br /> Business Name Wdii erenrfram above). Oj fyo l o V'a lfe ell'4 to ❑ (Avner ❑ Op:rator ❑ EmP'oyee <br /> Designated Operator's Phc mA; 9zy— 36 q ' 2 7— Q Service Technician ❑ ;#,ird-Party <br /> l tarnationel Code Council Certification#:??L{3 r�`7— v 4T. Expiration Date: <br /> ALTERNATE 1 <br /> Designated Operator's Name; Relation to UST Facility(CrZecx Are) <br /> Business Nam(if different from above): _ ❑ Ownar ❑ t7lxrator J Employee <br /> Designated Operator's Phone 4: _ G Sen ice Teehniciat Q 'bird-Party <br /> International Code Council Certification d': Expiration nate: <br /> ALTERNATE 2 (Opdorr <br /> Desiy,.n=d Operator's Name: Relation to UST Faci':ity;C'hecx One) 1 <br /> BusinesName(Jfdifterent from.above): C ( wftr ❑ Operator ❑ Er-npioyee <br /> Designated Operator's Phone#: C Sen ice Technician 13 7 hind-Part;; <br /> International Code Council Certification P: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY SITIST BE NOTIFIED OF ANY CI MAGES TO TIM <br /> INFORAMTION WITHIN 30 DAYS Of THE CH"GE. <br /> 1 certify that,for the facility indicated at the top of this page,the individual(s) listed above iNill <br /> serve as Designated UST Operator(s;. The individual(s)will conduct and dcac irnent monthly_ <br /> i facility inspections and annual facility employee training,in accoreartm with California Code of <br /> j Regulations,title 23, section 2715(c)-(t). <br /> i Furthermore,I understand and am in compliance With the requirements(statutes, j <br /> regulations,and local ordinances) applicable to underground storage tames. i <br /> NAME OF TANK OWNER t <br /> OR OWNER'S AGENT(Please Print): L zz2 X <br /> 1 SIGNATURE OF TANK <br /> OWNER OR OWNER's AGENT: !! <br /> DATE / >�OWNER'S PHONE# <br /> ELI <br /> September 2004 <br /> -5 an gar Wr-0,1 <br />