Laserfiche WebLink
7004 1160 0001 7398 4476 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with U i t <br /> s , <br /> Facility Name: T-Pj/1,b5 c,ll.•. C4A,. Q Faci(it i <br /> Facility Address: Reason rph ( heck One) <br /> ca' <br /> Shp <br /> siP� R bF1�r��oTr <br /> Facility Phone -7t . tiSr 1 O ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: ��� 4sb 6d Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: (b � �� ❑ Service Technician ❑ Third-Party <br /> international Code Council Certification#: %y —t>t� Expiration Date: Z i <br /> ALTERNATE l (Optional) <br /> Designated Operator's Name: 'W L,`S Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator Employee <br /> Designated Operator's Phone#: Gf I to !��'t 4.y ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: ',23 (p'.Lve� .- vimExpiration Date: &�� ve <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: SON Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner ❑ Operator employee <br /> Designated Operator's Phone#: f'l l -1 ! �® ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: �y�j���, V C__ Expiration Date: <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with 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: !Z �'L'1 I DSI- OWNER'S PHONE#: 1 Jai t 'LV!;-1iD <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.watei-boards.ca.gov/tist/contacts/cupa ag sy html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />