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Dec 28 04 02:01p Gabriel Urrea (9161 727-2 p.2 <br />L^ll ��`'�I' 11 <br />DEC 3 0 2004 <br />ENVIRUNIAENI HEALTH <br />- ;cRIiIrES <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: ', ( /' &,�" <br />Facility ID #: ``,�4 -600-3-777 <br />Facility Address: / -2 y X C r <br />S rdN CX- �S2e <br />Reason for Submitting this Form (Check One) <br />b/Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: Z C ��J - C/14 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: L <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Third -Party <br />Business Name (Ij&fferentfrom above): L', 5 <br />Designated Operator's Phone #: l��j 6 g _ ,3g <br />International Code Council Certification6 '� (�3 - (�� <br />Expiration Date: <br />AI.T6RNA71W 1 Ifi i;.....11 <br />Designated Operator's Name: 'T0 y STON <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (1fdierent from above): 0. z� . S <br />Designated Operator's Phone #: 0 Z97 -el77P <br />International Code Council Certification #: 5.2 - u e <br />Expiration Date: <br />ALILKNATEz (Opdonat) <br />Designated Operator's Name:jC'f/,��L Relation to UST Facility (Check One) <br />Business Name (If different from above): S ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (9/6 02 Z6 .-2.2-03 i ❑ Service Technician �$ Third -Party <br />International Code Council Certification #: Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER _�� L,f <br />OR OWNER'S AGENT (Please Print): AC <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: �� ' -c) y OWNER'S PHONE #: ( .2 S- r o(S <br />September 2004 <br />