HomeMy WebLinkAboutUST OPERATOR 12/28/20048 04 03s26p Cheryl Young
661-631-3872 p.l
Owner Statements of Designated Underground Sto~age Tank (UST) Operator
and Understanding of and Compliance with UST Requirements
Nsme: Mosa Marin Food MaidNocthw~ Chovron
Address: I 1101 Nighwe~ 178, 8akcrst~ie~d. G- 9330
(CicY)
Phonc R: 661-366-4886 _
FBCilily ID p: 7'KMT44-042992
Rca4on Tot Submirting this Fwm (CkeuE OneJ
O Changc of pcsignatcd Opcrator
O Ui-dale Catifitstt ExpiraQon Date
Desi t U T O erato s for this Fscili
PRIMARY
Dtsia+~oed Opeeacor's Name: Dougl~ M. Young I[1
Relacion w UST Faeiliry (Cbeck 0++~
Business Nmne (!J'd~'eroa~rt jran aboaeJ: Confidemce UST Servicv. l~ne. O Owr~cr O Upesaio~ ^ Employoe
p~y~~q~ Opqator's Phmte p• 800-339A930 ^ Serviee Technicinn W Third-Party
Inlematio1191 Code Countti~ Certitica[ion t1: OB7A646-UC SxPiration Dale' Ot~ober 14, 24~
AL~1 L' K7~A ~ l`+ i w+a~
~~~a o~•s N~-~: ~-~ ~ S
Rclacion ~o UST Paci~iry (Check Onr~
Duainc~ Name (/jdi,g'eiamj-oA+ aboveJ: ~jf1. L~ ^(?wner O ~(~tot b EmployCe
Dosignatod Opetator's Pbono g: -~ Q- ~ O Savice Technician ~hird-Porry
Idtcrneiional Code Council CCetificatia+ ~: ~,~ ~(P - l.l~ &upif'fltion Da[e~ 12 C.~
ALTEIi19A7 l!. z W-~m
pwignatod OptrdWS's Name:
Relntion to UST Fatility (Chsck OneJ
Buainas Nmna (Idlffereml++vm abo-"e)- O Owner Q Opuator 0 6mployee
Desigiated Ope~or'e Phone it, o Servico Tecbnician d'fl~ird-Party
Int~crnetlanal Codc Cou~cil Cett~fication tl. ~xp"vation Dale: _
I cextify that, foi ihe facitity indicated at the top of this page. the individual(s) listed above will
serve as pesignated UST Operator(s). The individual(s) will conduct and document monthly
facility inspecdons and annual fe+cility employ~ee trainin,g, in accordancc with California Code of
Re~,nilations, title 23, section 2715(c) -(~.
Fw~t6eco~ore, I und~est~nd and am ih com(diaece with the requirements (statutes,
regulatious, and [oc~l vrdinaates) Apptic~ble to ~ndergroand stotage taaks.
NAM6 OF TANK OWt~IER (Pleax
SIGIYATURE OF TANK OWN~R:
DATL• "~ OWNER'S PHON~ ~-s 651-97&0015
NOTB: 1) SUBMIT THIS COMPI.QTED FOKM TO THE LOCAL ACENCY (lYOT THE STATB'WATER
RESOURCBS CONTROI. BOARD) BY JANUARY 1, 2005. Tw~ ~ACAL AC6IYCY LIST lS AVAlIrAB~.E
AT: www watCrboards•ca.eov/usVcont~ISLg, oa ys.htmt.
2) NOTIitY THg LOCAL AGENCY OF ANY CNA1vGt'5 TO THIS 1NFORMATION WiTHIN 30 DAYS
O~ THE CHANGE.
NovemDec 2004
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