36C26219Q0018-005.pdf

November 2004

Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements

Facility Name: Facility ID #:

Facility Address: Reason for Submitting this Form (Check One)

Facility Phone #:

□ Change of Designated Operator

□ Update Certificate Expiration Date

Designated UST Operator(s) for this Facility

PRIMARY

Designated Operator’s Name: Relation to UST Facility (Check One)

Business Name (If different from above):

Designated Operator’s Phone #:

□ Owner □ Operator □ Employee

□ Service Technician □ Third-Party

International Code Council Certification #: Expiration Date:

ALTERNATE 1 (Optional) Designated Operator’s Name: Relation to UST Facility (Check One)

Business Name (If different from above):

Designated Operator’s Phone #:

□ Owner □ Operator □ Employee

□ Service Technician □ Third-Party

International Code Council Certification #: Expiration Date:

ALTERNATE 2 (Optional) Designated Operator’s Name: Relation to UST Facility (Check One)

Business Name (If different from above):

Designated Operator’s Phone #:

□ Owner □ Operator □ Employee

□ Service Technician □ Third-Party

International Code Council Certification #: 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(c) - (f).

Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks.

NAME OF TANK OWNER (Please Print): ______________________________________________

SIGNATURE OF TANK OWNER: __________________________________________________

DATE: ________________________ OWNER’S PHONE #: _______________________________

NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER

RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE

AT: www.waterboards.ca.gov/ust/contacts/cupa_agys.html.

2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS

OF THE CHANGE.

http://www.swrcb.ca.gov/ust/contacts/cupa_agys.html

Designated UST Operator(s) for this Facility