HomeMy WebLinkAboutOWNER STATEMENTS,, ~G a
pwner Staxements of Designated Underground Storage Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Facility ID ~: ,~ 9~~
F~~~~~, N~e: Fasttip #6 (E~ocon) R~on for Submitting th~s Form (Check One)
Facility Address: 1640 So• Che~ Avenue' Ba1~~e~d' CA 93304
O Change of Desigt-ated Operator
~C~~'~ p Update Certificate Expiration Date
Faciliry Phone #: 661-397-8606
lles~ ated UST Operator(sl for this Facili
PRIMARY Relation w UST Facility (Check One)
Designated OPerator's Name: Douglas M. Young lll ~~~or ^ Employee
Business Natr-e (/f d~erent from above): Confidence UST Services, Inc. ^ O~~ 'I'hird-Party
^ Service Technician ~
p~~$n~~ pperator's Phone #: 800-339-9930
Expiration Date: October 14, 2006
Intemational Code Council Certification #: 087864b-UC
ALTERNATE 1 uona .
Designated Operator's Name: ~ _
f3usmess Name (1f di~j'~e~ent from above): ~j(~E-' ~
Designated OperatoPs Phone #: ~ C~~('~~ -~~
Intemational Code Council Certification #: 5a. ~ C9~~ ~
p~~~~~ pperator's Name:
Business Name (If di,,Q'erent from above):
Uesignatecl Ope~~°r's Phone #:
Intemational Code Council Certification #:
Relaii ST Facility (Check One)
^ Owner ^ Operator ^ Employee
^ Service Technician ~ird-Party
Expiration Date: ~ ~ 1~--) v~
Relati- on to Ug'~' Facility (Check One)
^ Owner O Operator ^ Employee
O Service Technician ^ Third-Pariy
Expiration Date:
the individual(s) listed above will
I certify that, for the facility indicated at the top of this P~il conduct and document monthly
serve as Designated UST Operator(s). The individual(s)
' s ctions ar-d annual f~ility employee training, in accordance with Califomia Code of
facihty ir- pe .
Regulations, title 23, section 2715(c) -(fl•
Furthermore, I understand and am in compliance with the requirements (statutes,
licable to underground storage tanks-
regulations, and local ordinances) aPP
NAMIE OF TANK OWNER (P~ease PP1O$)~ ~` ~ a V ~J 1~ ~~` S `~ ~~~' ' 1 L L L' ~-
~ -
SIGNA'Y'URE OF TANK OWNER: /~i .
~.. ~ ~ ` ~ pwNER'S P~oNE #: 661-393-7000
DATE: ~
OTE: 1) SUBM[T THIS COMPLETED FORM 'T~ ZOO ~NE LOCAL AGENC Y ST IS AVAILABLE
N BY JANUARY 1,
RESOURCES CONTROL BOARD)
AT: www.waterboards.ca. ov/ust/contacts/cu a a s.html.
2 NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORM~-TION WITHIN 30 DAYS
)
OF THE CHANGE. November 2004