Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />Facility ID #: <br />Facility Address: i 2 W <br />&-t <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />Update Certificate Expiration Date <br />Facility Phone #: f <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: La <br />maLun <br />Relation to UST Facility (Check One) <br />❑ Owner Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: - ? <br />International Code Council Certification #: <br />Expiration Date: I 12TLWL--3--1 <br />ALTERNATE I (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdifferenifiom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dii ferent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 �-�'r� <br />OR OWNER'S AGENT (Please Print): _e e L wIKpMOr j <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: _ 10 Lf /1( OWNER'S PHONE #: � (( 6- 3R�- 37I b <br />September 2004 <br />