COMPLIANCE INFO_2004-2009 - Laserfiche WebLink

Home Browse Search

ibec 20 04 12:00p A* Sibley - Sr. HSE Co 70-452 6947 DEC 3 U 2004 r r a Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of Compliance with UST Requirements p.5 Facility Name: --H- 13 I Facility ID #: 13 r Facility Address: �y O,r q 4 ) ��Cw� 1 ea-, Reason for Submitting this Form (Check One) X Change of Designated Operator ❑ Update Certificate Expiration Date Facility Phone #: Designated UST Operator(s) for this Facility DOWMAVv Designated Operator's Name: S /f e u.. y S H4 d L Relation to UST Facility (Check One) 0 Operator 13 Employee ❑ Service Technician X Third Party Business Name (Ijdifferent jrom above): D Ln+ 1'1 v. ouA1eurAl COUSkAr.4owner Designated Operator's Phone #: b _ �� International Code Council Certification#:u,v4vajcraace Pks4„j6 RaPamr Expiration Date: Nor r}ropLic�+r5�� Ai7TQtNATTr 1 111*6anaA Afi'Jct Designated Operator's Name: t- rL 2 , fk 6 ,, S Relation to UST Facility (Check One) Owner 0 Operator 0 Employee 0 Service Technician X Third -Party BusinewName (Ifdifferertfromabove). QC7LT✓1 £eJ1J20u.ti,eA)rAL CMU! Designated Operator's Phone C O - 7 Da- - 0 S7 c/ International Code Council Certification #: I y _ L Expiration Date: 9 A t 77i1QN A Tip � in.,.ra,.an Designated Operator's Name: in-„ Vr�Au h ,t 19L4 A TS Relation to UST Facility (Check One) O Owner 0 Operator 0 Employee 0 Service Technician X Third -Party Business Name(Ifdifferentfromnbove): peLrn £uu� oun,eC �av�arv� Designated Operator's Phone #: 6 3,- 6 p - e 7,s 7 International Code council Certification #: , �L 3 C u 9 1 — U,- Expiration Date: 6 y t oe 6 1 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 (Please Print): SIGNATURE OF TANK OWNER: DATE: OWNER'S PHONE * NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS "ARABLE AT: i"vw.waterboards.ca.eov/ust/contacts/cum aws.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.