Laserfiche WebLink
J111--11010 14:18 FROM:LOKMAN FINANCIAL CRO 2094760220 TO:4683433 P.1 <br />Owner Statements of Designated Underground Storage Tank (UST) 2010 <br />a <br />and <br />Understanding of and Compliance with UST <br />FacilityNamc: a a Fact ity ID #: = s r s t ; , ;7741 <br />Facility Addr= I Reason for Submitting this form (Check Otw) <br />)e Change ot'Designated Operator <br />Facility Phone # Update Certificate Expiration Date <br />Designated UST Q2erat9r(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Karen R Arnaiz Relation to UST Facility (Check One) <br />'Business Name (/fdWerent from above).- fa Owner 0 Operator ❑ Ernploycc <br />Designated Operator's Phone #: (209) 518-4836 G Service Technician K Third -Party <br />International Code Council Certification #: 8032295 -UC Expiration Date- 06/20/2011 <br />.Designated Operator's Name: <br />Relation to UST.Faeility (Check One) <br />n (honer rl Operator n Employee <br />❑ Service Technician ® 'Mird•Party <br />Business Name (Ifdii erentfrom above): <br />Designated Operntoes Phone #: <br />#lnternational Code Council Certification 0: <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 0 Third.pnrry <br />Business Name (If difj"ereaf from above): <br />Iwsignated Operatne% Phone #: <br />international Code Council Certification #: <br />Expiration Date - <br />1 ccre4 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 <br />NOTE: 1) SUBMIT THIS COMPLETED :FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1. 2009. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards,ca.eov/ust/contacts/cutza aevs.html. <br />1T THE CHANGE, <br />November 2004 <br />