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" DEC 3 0 2004 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name--- �, q_7 # L Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> C,✓ C- �t ,,,,„ n ❑ Change of Designated Operator <br /> 1 <br /> Facility Phone#: 'z.{VloJr� y- o E3 Update Certificate Expiration Date <br /> Desismated UST Ouerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: L, Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): '� r _ ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:i�JZ _ c) _ ❑ Service Technician Third-Party <br /> International Code Council Certification#: Z4 Z6( Expiration Date: <br /> ALTERNATE I ' nal <br /> Desi isName: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from a ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expvatton Date: <br /> ALTERNAT <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 'ration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF NY 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 <br /> OR OWNER'S AGENT(Please Print): I\ R I� l S 1 G fl <br /> SIGNATURE OF TANK n1I <br /> OWNER OR OWNER'S AGENT: of G <br /> DATE: O4 ' OWNER'S PHONE#: ;ZO — O-59 'I 110 <br />