Laserfiche WebLink
owner. Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Coinp]i ance with UST Requirements <br /> Facility Name:Quick N Stot Mail, Facility ID#, <br /> f I Rm;n for Submitting this Form(Check One) <br /> Facility Ad 2057 S.TV lDorado St or 'i t do (Check <br /> One) <br /> X Change of Designated operator <br /> Stock-ton,CA.95206 Certificate <br /> .0 S int <br /> t2 Update Cortificato expiration Date <br /> Facility.Phone ft:(209)463-0474 <br /> Desi mated UST 0per_atojrs <br /> j for thisFaciliq <br /> PRIMARY Rclation to UST Facility(Check One) <br /> Facility <br /> n <br /> Operator's R Arn Employee <br /> jDes <br /> ,ignate(I Operator's Naime:Karen R Arnsiz <br /> B b 0 Owner Cloperator 0 Employ= <br /> Owner <br /> 0 7 hird_P <br /> 7 s Nam (If different from <br /> a 01 Service Technician X T <br /> Business Name(If different frOm ab0`0-' <br /> 0�) 5 8 �j a Service Technician X Thir&Party <br /> or <br /> Desipated 0 Is, onc#,(209) 518-48,16 <br /> Perm ratio to,07/1 9 <br /> i� q ( - rO 0 <br /> Txpira�on 1)atc:07/16/09 <br /> Fxp <br /> rn tj� Code <br /> rti )2 <br /> International Code Council Ccrtir00100n i�'5266643-UC <br /> ALTERNATE I oval <br /> Relation to UST Facility(Check One) <br /> �'iirnc. <br /> Designated Operator's Name; <br /> ')c M -3 <br /> r <br /> P0 we 0 Owner <br /> BuslZmg Name Of diffelhintfirOln above): 0 owner C1 Operator 0 EniploYcc <br /> o Scrv&iccTccWcian n- Third-party <br /> .Eluq <br /> D P tc� Operator's <br /> esignated Operator'-,Phone#- <br /> .1 , r <br /> ;X iMtion T.)ate. <br /> International <br /> odcC I Expiration Date* <br /> Internatiorial Code Council Certiflcati0f) <br /> ALTERNATE 7 (OPd&ndf) Relation to UST Facility(Check One) <br /> .Designated Operator's Name: <br /> C1 Owner 0 Operator 0 T'.MPIOycc <br /> Im <br /> Business Natile(if differentfrom above): or �•lp" <br /> I [i sci-viceTechnician 0 TMhird-Party <br /> Designated F);;r—ator s Phone 0: <br /> 0 <br /> International code Council Certification 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 or <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 /> NAMEOF TANK OWNER(Please Print)' <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 1.1/19107 OWNER'S PHONE 4 )-PV <br /> NOTE: 1)SUBMIT THIS COMPLETEDFORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY.IANUARV 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:w_WW.wqt_crboard.&.ca y1qj <br /> . o VcqntqqtjNWj-8Ry-%zhtM-1- <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> Noverriber 2004 <br />