Laserfiche WebLink
Luoo-ijB-mmmj/:d:44 4!S1A'U014eWj(4U1 ajow J0=1 *JGAIQS Xe4 jqewXvd IjE)Aq peApoei Sem M <br /> siflECEIVED <br /> F:mffr Frur"n-Hill loc. Ttv 120MOib3 Pagel:212 Vzte:liM4/2012 11:24,30 AM NOV 2 9 2012 <br /> RONMHEALTH <br /> Owner StAtoments of Desiguted Underground Stomp KENTAL <br /> Tank(UST)OperEPMIT/SERVICES <br /> and Understanding of Compliance with UST Requirements <br /> DeAlmayd=gp.MtOKIN for We FA <br /> Wkly NAM:goolic,r1a FAQ*ID <br /> PUMP/Ad*665. BOO Victor Road x4mil for submittin*6 Form(06,*Ono <br /> Lod,dA 95240 C1 CaW of Designated Opor" <br /> 0 YZL*C081ficaft ftnation risto <br /> MOM <br /> owivulwa opeotot's WWO.-X06hus awwn Relation to UST Facility(Check One) <br /> WaRM W440a STVrdWjP0*dkWe).'Fr&nZdn-HW Ino. 0 owner a operaW (3 Imployou <br /> 2!�ivwW 0 668-2917 1--Smioe TedwWan X ndn0mv <br /> �-omwes (521 — <br /> kmWioml Co*CoUroll Catificatian M 00209977-Ud fthy4w Date!09/1312014 <br /> ALTMATZ 1&t6nd <br /> DuWated QpcatW6 Now Jwwa Flatware PAM10A W VFr hCWIY(0404 ON) <br /> Ruameas Name WdWaradAm abp%V?rwzm41dJ a omw a opmtm 0 Emyac"Q <br /> D44WANd Oph2bas ftem#',(559)6&&T;77 OSavice Tedmiolui QThir&Paty <br /> ktaygdoytil Code cd=il.carff"UN 0:803033.IUC Bt*910n D&W 03/01/2013 <br /> A=(NATE 3 (Opd"4 <br /> pesip*d C*MWO Rome:Adam Taylor Relation to UST Focikiv.pea 040 <br /> Sudinaa N4w(#1ddb*vfmm aboya):Pr4awaft in owner 0 opaswe 0 Employs* <br /> NQtAUd!?pwator's Phone#.(S59)6W2917 0SMiCa TVdMiG18A 0T*kd-PUW <br /> IrAnnational Qj*CoumB Cmiffientim0-,5311579-UC <br /> I cwiii�than,ibr the Mlity indicated at the top of this pag%the indMdutl(s)listed above will <br /> nerve as Designated UST Opaatw(p). The individual(s)will conduct and dMument mouttily <br /> fuility inspeWous and aoAusl tacility anploym uniuin&in&oeWwA*with California Code of <br /> ReguWon%tifle,23,Section 2715(c)-(t). <br /> Furdmawre.I mderstand and ant!-a cwtPliate with the mqWrenvots(d4tutes, <br /> rt&dstt1*rw,,gaa local ordliumm)appNeable to tiftZround storage tank& <br /> SAM OF TANX OWNER Mean 11601 4&%kt.Q <br /> SIGNATURE OF TANK OVVNML <br /> DAr1& OWMM-SrsoaN. 16— 24 1--S-7 76, <br /> Soni 1)SUBMT 7W8 COROLLPM YOM To M LOCAL AGENCY O(OT TIM STATE WATER <br /> 919OURCES CONTROL BOAkD)BY JANUARY 11;8K THE LOCAL AGINCV LIST IS AVAMADLE <br /> A'l't!ynxva 9&a WLr'L&0(/W W=Vk W k—BAU <br /> 3)NOTWY TH3 LOCAL AGZNCY OF ANY CUNGES TO TMS INFO TION'WIT=30 DAYS <br /> OF TRE CHANGE. <br /> November 2004 <br /> This%x was sent with GF1 FAXmWr fax wwr,Faf More Information,Mait http:#WW.96,0aM <br /> Wd 9 V6VP Z WZ/9 W 1.1. :9480 L/L :9612d umouNun :woj=l <br />