Laserfiche WebLink
Mar. 1. 2016 2:19PM <br />RUMEX CONSTRUCTION No.5513 P. 2/2 <br />Page 2 of 2 <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR <br />103=EIV <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQM ED <br />For we by Unfdoa MenberAgendw or where approved by your Local Jurisdiction <br />Authority Cited., Mle 23, Div. 3, Ch. 16 California Code of Regulations (CCR) MAR 0 12016 <br />FACUM N"S FACILITYPHONE <br />Calgomia Highway Patrol - Stockton C 209.) 943-8666 ENVIRONMENTAL <br />FACV,IrfSITB ADDRESS CITY <br />3330 N, Ad Art Rd. Stockton, CA 95216-2241 <br />REASON FOP, SUBMITTING THIS FORM (hack One): 0 Change of Designated Operator []Update of ICC Certification Expir4oft Date(s) <br />ren rtes ersv l.y A.,rvrk TTarf, nnvio Airnn VnD q° MQ IrA rn r1rV MCMMATTM <br />OPERATOR NAME.: PLEASE SEE PAGE I OF 2 <br />RBLATION'M UST FACILITY (Cheek One) <br />0 Owncr [I Operator [I Employee <br />[] Service Technician Third -Party <br />B(-ISIM3$$UAMPI�lf-diffe--ttfto-abow): Rumex ConstivotionCorpo 'on <br />DeSIONATED OPERATOR P14092., (559)371-:3300 ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: <br />MUM= DATE, <br />ALTERNATE I DESIGNATED UST OPERATOR FOR TEaS FACHATY(Opfidmal) <br />I)PSIUNAT8DOPERATOR NAME: Jack Mendrin RELATION TO UST FACILITY (Check Ow) <br />iW4 9S _NAX (9rdVaqn1fram above): RurneX Construction Corporation E] Owner [] Operator Q Employee <br />DESIGNATED OPERATOR PHONE: (559) 271-3300 ext, ®service Technician Thud -Party <br />INTERNAnONAL CODE COUNCIL CERTIFICATION NO.: 8225062 WMATIONDATE. 4/17/2017 <br />DBIGNATED OPERATOR NAME: DeAnna Davis <br />REIATTON TO INT FACILITY (checkohe) <br />0 owner 0 operator El Employee <br />0 ServiceTechnician Third -Party <br />BU,SWB9.NAMEWdi*onrfrom4bove): Rumex Construction <br />D29YONAMD OPERATOR P140MEz (550) 271-3300 ext <br />INTEMXTIONAL CODE COUNC[L CULTIFICATION NO.-. 8376415 <br />WmAnONDATF- 8/1912017 <br />ALTE"ATE 3 JIJFhUirqA1'y,-V UI}! UMMAL UR VVIC A WO V At,"'A L x (UPOOKay <br />Dtsfrj OPERATOR NAME: RELATION TO UST FACILITY (neck One) <br />SUSINBS NAME 0fdomtfroln above); D Owner El Operator 0 Employee <br />UE -9 D—N—AT75 OPERATOR DRONE: ext. ❑ Sowviet Teelmician ❑ Third -Party <br />MMN,tTlYN-,iL-CODE C-OUNCIJ,CERTIFICA-rIONNO.: MXff _.. <br />I certify that, for the facility indicated at Che top of this page; the individual(s) listed above will serve as Designated UST <br />Operator(s). The individunl(s) Will conduct and document monthly facility inspections and annual facility employee trahifilff <br />In accordance with California Code of Regulations, Title 23, Section 2715(c) through (i), rmore, I understand and am <br />in compliance with the requirements (statutes, regulations, and local ordinances) appikable to underground storage taula. <br />- i '3 W -no am - I; ';I Z - <br />TANK OWNEX TITLE: <br />TANK OWNER SIGNATURE: <br />ranomwomm <br />OWNERPRON76- ( 916 ) 843-3800 <br />DATE: &I lswk, <br />1. Rep <br />.prt the naMe(s) of the Designated UST OPcrator(s) as registered with the International Code Council (ICC). ICC certification <br />infbrmadoA is available ort -lice at: www.icesafe.orgleltertsearobhuW. Search for "California UST System Operators:" <br />2, Submit this completed form to the local agency that regulates this facility's USTS. Uniclocs member agency jurisdictions and <br />contact information are listed on-line at: www.untdocs.org/members*horegulateswhat.htmL. Contact information for other <br />local agencies within California is available at: www.ffwreb.ca.govlcwphoraefust/cont=Wdocallocal._Agency__4kjds. <br />3. 23 CCR §21715(4) requim that you notify the local agency of any chingeg to diis,ifformat.ioni4ithlil 30 days of the date of change. <br />(N-062 - 111 wwwmakdamort OW27jo5 <br />