COMPLIANCE INFO_2011-2013 - Laserfiche WebLink

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Owner Statements of Designated rground Storage Tank (UST) Operator and Understanding of an iance with UST Requirements Facility Name: ARCO 05450 Facility ID: 05450 Facility Address: 1617 W FRE mo N-T-—- Reason for Submitting this Form (Check One) XX STOCKTON, CA 95203 N Change of Designated Operator Facility Phone#: 209-462-1617 El Updated Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Cristina Pena Relation to the UST Facility(Check One Business Name (If different from above): Belshire Environmental Services, Inc. El Owner 11 Operator 0 Employee Designated Operator's Phone#: (949)460-5200 F-1 Service Technician ■ Third-Party International Code Council Certification#: 8010939-UC Expiration Date: 517/2014 ALTERNATE Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document El Owner El Operator 0 Employee Designated Operator's Phone#: refer to backup document El Service Technician E Third-Party International Code Council Certification#: referto backup document Expiration Date: refer to backup document J ALTERNATE 2 Designated Operator's Name: refer to backup document Relation to the LIST Facility(Check One) Business Name (If different from above): refer to backup document El Owner El Operator El Employee Designated Operator's Phone#: refer to backup document El Service Technician ■ Third-Party International Code Council Certification#. refer to backup document Expiration Date: refer to backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - ft Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Sarah Samuels Signature of Tank Owner: Date: 8/19/2013 Owner's Phone #: _(M) 371-1500 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:www.waterboards.ca.gov/ust/contacts/cupa_agys.htm]. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.