Designated Underground Storage Tank (Ust) Operator Monthly Visual Inspection Checklist

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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)
Change of Designated Operator
Facility Phone #:
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):
Owner
Operator
Employee
Designated Operator’s Phone #:
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):
Owner
Operator
Employee
Designated Operator’s Phone #:
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):
Owner
Operator
Employee
Designated Operator’s Phone #:
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:
2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS
OF THE CHANGE.
November 2004

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