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HomeMy WebLinkAboutUST REP. 7/25/2010 IIIIIII VIII IIIIIII 23 IE UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND U N DERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited. Title 13, Div.3,Ch 16 California Code of Regulations(CCR) \r•'!I I'I"1'N:1M1•: � ` FACiL[TY�I PHONE� O — O,� I!_I I'`r';I.1 F ADDRESS CITY Lisp. Map'el 13al er&f reld l� Q i:"ASON I OR S t 113MITTING III IS FORM(Cheat One): Chan a of Designated grated Operator CCUpdate of ICC Certification Expiration I)atc(s) '-'RIMARY DESIGNATED UST OPERATOR FOR THiS FACILITY 1 i1i i1dA l'IiD OPERATOR NAME: RELA110N TO UST FACILITY(Check One) "I ISINF.SSNAME(/jdifferenrfrowabove): �k ( ❑ Owner [I Operator [I Employee !Y+1'Siri?11A•I1{0 OPERATOR PHONE: � GJI � rJ _ 6!5/ eXL ❑ Service Technician ©'Third-Party 1 it I.RNA'llt 1NA1.CODE CUl1NCIL CERTIFICATION NO.: a 5 C EXPIRATION DATE: aSUI rJ A LTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY oe i I�i;SIONA'I ED OPERATOR NAME: e '4e c L RELATION TO UST FACILITY(Cheek One) iii t-SINI;.SS NANIri(lfdi(jemntfronrabow): v Oµ ^_ ❑ C] Operator ❑ i:mployec I WSR NATI:I)OPERATOR PRONE: G _ eXL E] Service Technician �fhir(l-Party L__ 1 :NI RNAT IO NALCODECOUNCILCERTiF1CATiONNO.: O 55 _ L. EXPIRATIONDATE:10 3i c�L)U I---- '- -J,TERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdonal) { i dI `;Ir iNAI 1,1)OPERATOR NAME: Daniel 1'ser RELATION TO UST FACILITY(ChecA One) "Iil11W1;4 NAME(II'dierenJfromabove): ' i oil ❑ Owner E] Operator ❑ 1:lnphyce ^I.1;IIiN-\'I'lig(1PIRA"fORPHONE s 3_ 53 ext. ❑ Service Technician [Ihird-t'arty v i;d 1*1 RNA 110NAI,CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: G j�ll: A i.rEIiNA,rE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdonal) li-',. r.tNA•1 FD OPERATOR NAME: ' Qrn s RELATION TO UST FACILITY(Check One) Ill i:;INl.lti N,1Mli(!fdlffenemfmnrobove): U C ❑ Owner ❑ Operator ❑ Emplovec t I `;Ir iNA 11:1)OPERATOR PtiONE: � � -7 7a ext. ❑ Service Technician t�]''I'hird•Pariy .M'I FRN,1 HONAI,CODE COUNCIL CERTIFICATION NO.: Sa�71 EXPIRATION DATE arJ 2Ul/ r_trtifv that, for the facility indicated at the top of this page, the Individual(s) listed above will serve as DesignalcA UST operarnr(s). The individual(s)will conduct and document monthly facility Inspections and annual facility employee training accordance with California Code of Regulations,Title 23,Section 2715(c)through ((. Furthermore, 1 understand and am compliance with the requirements statutes,regulatio an local ordinances)applicable to underground storage tanks. A"AV OWNER NAME: �Oee � "'a I,!h i OWNER'i'1TLG: OWNER PHONE: -( t±WNER SIGNATURE: DATE: 71a310cr IPISTRUCTIONS It:-pr•1 i the name(s)of the Designated UST Operator(s)as registered with the international Code Council(ICC).iCC certification information is available on-line at:www.iccssfe.org/e/certseamh.htmi.Search for"California UST System Operators." )ui)mil this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at www.unMocLorg/members/whoregulateswhat.htmi. Contact information for other local a,encies within California is available at:www.swrcb.co.goy/cwphome/ust/contacts/docs/local—agencyjistxls. S V11 a2715(a)requires that you notify the local agency of any changes to this information within 30 days of the dare of change. wwmucidomwg 24 09/22/09/22J05%IIIIIII VIII III III IE UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND L]NDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdx1ron Authority Cited Title 23, Div.3,Ch 16 Calijornia Code of Regulatiom(CCR) I-ACII.ITY NAME FACfLfrY PHONE t ACII_I'IoY SITE.ADDRESS C ^ a le t { R FASON PI)R SI IHMI]ITING THIS FORM(Check One): Change of Designated Operator MWpdaicofiCCCidificationFxpirationD ate(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY I)I SI(iNA 1'F.D OPERATOR NAME: Q RELATION TO UST FACILITY(Check One) L-- NAME(Ifdifferen1fromabove): J� ��,� G ❑ Owner ❑ Operator ❑ Employee r11)�rr[:JZNA'I"I()NAI-I:SI(iNA'fl:D OP ERATOR PHONE. ( C.7� a h _ ext. ❑ Service Technician E1'hird-Party CODECOUNCILCERTIFICATIONNO.: 1$955_ G EXPIRATION DATE. 11 a7 aQ// .kLTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY 1 II:S16NATED OPERATOR NAME: Tim RELATION TO UST FACILITY(Check One) miSINE SS NAME(/fdijj'erenffmmabo* ❑ Owner ❑ Operator ❑ Employee O SIONATED OPFRATOR PHONE: 51 } 3y _ 7a ext. ❑ Service Technician 03'TS,ird-Party U'IT IZNA'rI()NAL CODE COUNCIL CERTIFICATIONNO.: 5Q95Qqq- a G EXPIRATION DATE: 13 ,9(O awo kLTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY I 1)1-.SI1 NATI:D OPERATOR NAME: + RELATION TO UST FACILITY(Check One) IIIISINI--SSNAMhQ(dfferenifrornabove): Tan ❑ Owner El Operator ❑ Employee of SI6NATEDOPERATOR PHONE: ( O ext. ❑ Service Technician [Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: gM `f74 uG EXPIRATION DATE: 7 1 ldcq AL,rERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Op and rl)C?SIONATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) I31. SINt:SS NAME(IfdlffervMfrom abow): ❑ Owner ❑ Operator ❑ Employee I)I'.SF NATED OPERATOR PHONE: ext. Service Technician E] Third-Party IN I'I-:RN A,rIONAL 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(t)through(1). Furthermore,I understand and am in compliance with the require nts(a tea,rep latioas,and local ordinances)applicable to underground storage tanks. .ANK OWNER NAME: �S Z OWNER TITLE: — OWNER PHONE: — a.� TANK OWNER SIGNATURE: DATE: 7/ /Ucf IN TRUCTIONS I. Repoli Uie name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC). ICC certification information is available on-line at:wwr.ictsafaorg/t/certaearcLbtmL Search for"California UST System Operators." :.'ubniit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and :ontact itifor'mation are listed on-line at www.unidoeLorg/members/wboregubtawbaLhtmi. Contact information for other local agencies within California is available at:www."mb.ca.gov/cwpbooWusVcontacte/docLlmlLapnq_lisLxb. i. 23 CC§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. f i•Y-i16:- I/t ,pp,,r.en 09/22M