Laserfiche WebLink
06 <br />E'LL 2 4 C_ <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name:e eum — Kwik Sery <br />Facility ID #: <br />—B <br />Facility Addres O1 E. Ja son Ave. Escalon CA 95320 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: (209) 838-3971 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Rick Jewell <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />64 Service Technician ❑ Third -Party <br />Business Name: Boyett Petroleum <br />Designated Operator's Phone #: (209) 321-0017 <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 1 (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 different from 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 different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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) -,.,]pale Boyett <br />SIGNATURE OF TANK OWNER: <br />DATE: �Zf��/ �� OWNER'S PHONE #: (209) 577-6000 <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.waterboards.ca.gov/ust/contacts/cupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />