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HomeMy WebLinkAbout631 BAKER STREETV~. LL VVl -VJl 1 / I / ' ~a~~'^~~ ~^ • ••~~ -- Ovmer Statements of Designated Under~round Stora~;e Tac~k (UST) Operator and Understandi~ag of and Compliance with UST ,Requiremeuts Fotilily Name: tieker ~tauion Mmlcet ..... Fac;Gry o) 0. . . ~'7 l~n~tilit ~-d~sa: 63! l~nk.s 3w~t, Hakv:sCidd 1:A93305 V-L/~'- Y t2eLxon for ~ubntitting this i~crrm {C/necklJ~ej ~CnY) O Chimg~ 01 Iksignwed C~xalot h~uciliry VhOee p: !~(i1J~31-1717 O llpd'atc C;utilicalc l:xniration Ikae Desigaated UST O~rator(sl for this Fs~cilitv PR7MA~ICY l~tignated (~ator'v Namt: LJou8las M. Yout~t [ll Rclution tn I1S7' l~ucility (C%u:<-k (hiu) BLLV;,w.~, IJanpe (~fd{Be-rnrfroin a~ve): r_a.r/ieence uJT servrces. ~nr. o ckvrr~ o c~ratm o lsm~luy.x~ ikyi~naledl~ratn-'s Ifia~c N: KOU-J39-'N)3Q _. o ti~vik ~1'a:hnicinn p lhinl-Nsrty btternieGamaJ Code Camcil Uitilicalion fJ' (IN'7tiG46-lJC: I:xpinuion 1'Aw: Ck:tolxz 10. 2WG ~ Iksignatea~f (fieretor's Name: ' ~ ~ ~ ~~ r ~,~,J ~ S ltelatiufn w lJti'f F'acilily (('hrek ()nr) Huune~ Name (/jdi,~er~ent jrw,r vbm+e): (' ^: 'n ~- ~ ~- ~ • il ( ~SJ. " O ( hvi~ [~ t ~r~m O M~mpioy~Y Ik4ignatcdOpautor'9 Pbout-c ~: ~~Q -~'~G'1 -~~ ~ S~icx'I'ahirician ~6'AiN-Par1.Y Inlemadonol Codc Cameil (:ritificatioo M: -{"'-~~ "rl a- ~ ~' ~ - t:apvation U~i4:: _ , / ~- ~ 'l _ •I.TRRN~TR 2 pA~im.s. T • Ik~igwted (~erat~'~ Nmne: Rala~ion to l)S~I' F'waJily (c'-~rck <hnr) Du~irnss Neme(/jdifjeren/jrorre above~: o Clwna O(~utor O I~anpioya: (ksignatedclpaetor's Phone q: O titrvice'I'ecfuiician C7 1'hicd-I'ar1Y ImetnnUon»1 Code l:iwr-a) (:alification tl: F:~qriratian 17atc: 1 certify that, for tl~e ficility indicated at the top of this page, the individuaf(s) listed above will serve as Designated UST Operator(s). Tbe individual(s) will conduct and documet~t monthly facility inspeetions and annual facility employee training, in acxordance with Ca{iforaia Code of Regulations, title 23, sectiop 2715(c) -(Q. FuAbermore, 1 ande~r'stand and am in compliance with the requiremeAts (statutes, r~gulatioaa, and bcal ordioances) applie,able to underground storsge taaks. [YAM~ OP TAIVK OWlrER (Pltast Priat): `~ ~ ~~ SICNATURE UF TANK OWNER: ~ ' ~ DATE: ~''- 3~'~ L,T, OWNER'S PHONE !/: 661-631-I777 NQTF.: 1) SUBMIT THIS COMP~,F•TBD RQRM TO TNF LOCAL AGEN~Y (NQT THE STA7"E WAT~K R~SOU~iC~S CO1VTat01. BO.ARA1 BX JANIUA,RX 1. 21t(-i.1fHE IACAL AGENCY t.IST IS AVAtLABLE AT: ~~~~~Y.~~:IICC~11YIrJ~.u~.gnVacl/con1:~G5/CUjF~~:~t~'~~.hU~~l, 2) I~IOTIFI! TN~ ~OCA~. AG~NCX ~~ A,NX CHANGES'r0 7'SiS INRORMATlON WITNIN 3U pA~YS OF THB CNANGL November 21104