Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: { E L — S <br />Facility ID #: <br />Facility Address: -7 1--7t,V , � � 4� S�� <br />C14 g S Z C) 6 <br />Reason for Submitting this Form (Check One) <br />Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: Z- O C) 9 3 9— 0 94� 1 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Qo�e!rV tiF.c <br />Relation to UST Facility (Check One) <br />�❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician `Third -Party <br />Business Name (Ifdifferentfrom above): (zel.cibl-e <br />Designated Operator's Phone #: (ZC co (oOt{ - C{ 33(x. <br />International Code Council Certification #: 5a5,�)S`I 0 ~ 0 C , <br />Expiration Date: t - 9 - c9 O I O <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): <br />SIGNATURE OF TANK OWNER: <br />�_, 6-TFA t <br />i/ <br />DATE: 74 <br />s, OWNER'S PHONE #: Q [7 �� <br />�T <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 />