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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use br Unidocs Member Agencies or where approved by your Local Jurisdictior Authority Cited: Title 23, Dir. 3, Ch. 16 California Code of Regulations(CCR) i FACILITY NAME 'j PF&J :SCe*�.1 CENA OT-' FACILITY PHONE (�axAJ':du>�.1 IrRRRG� ( ZOO } 46S ^ 2.06& CITY FACILITY SITE ADDRESS S�GKro Q i Z► 5, SA+a moa C,�� S"`�'r REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator pdate of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: T Ss E 9�um E1J RELATION TO UST FACILITY(Check One) i BUSINESS NAME(Ifdifferentfiomabove):QAt>�£yjtpRzZ�SC, Owner ❑ Operator ❑ Employee ( 2LKi ��4�a E:1 Service Technician [Third-Party DESIGNATED OPERATOR PHONE: ext. INTERNATIONAL CGDE COUNCIL CERTIFICATION NO.: 5-7435 EXPIRATION DATE ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Ontional) RELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: BUSINESS NAME(Ifdiflere,7t from above): ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician Third-Party DESIGNATED OPERATOR PHONE: ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) RELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: Owner E] Operator Employee BUSINESS NAME(If d fferent from above): ❑ ❑ ❑ Service Technician ❑ Third-Party DESIGNATED OPERATOR PHONE: ( ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO. EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(If diflerent from above) ❑ Owner ❑ Operator E] Employee ❑ Service Technician ❑ Third-Pam' DESIGNATED OPERATOR PHONE: ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 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)through (f). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: TANK OWNER TITLE: MA-*-'�6'F r^�t`'— -�T � OWNER PHONE: TANK OWNER SIGNATURE: DATE: Z Zy fJ INSTRUCTION'S I. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ]CC certification information is available on-line at:www.iccsafe.org/e/certsearch.html.Search for"California UST Svstem Operators." '. ulates this facility's LSTs. Unidocs member agency jurisdictions and Submit this completed form to the local agency that reg rg/members/whoreguEateswhat.html. Contact information for other contact information are listed on-line at: www.unidocs.o local agencies within California is available at:www.swreb.ca°ov/cwphomeiust/contacts/does/local_agencylist.xls. CCR =??�(a)requires that you notify the local agency of any changes to this information within 30 days of the date of chance. Lt\-062-1/1www.unidocs.or_ 04/22/05