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� w <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility ID#: <br /> Facility Name: a Reason for Subasahng this Form(Check One) <br /> Facility Addmss: ❑ Change of Desigmtod Operraor <br /> (J g + ---_ ❑ Update Certificate Expiration Date <br /> Facility Phone#: , Or ts <br /> Designated UST operator(s)for this Facility <br /> PRIMARY Relaum to UST I —.j(Check One) <br /> Designated Operator's Name: 13 t�lo9a <br /> ❑ Owner ❑ Operator <br /> Business Name(II ifl�emni from above): Third-PaM1y <br /> ❑ Service Technician <br /> Designated Operator's Phone#:C12, - <br /> 'ZExpiration Date: <br /> tnte loonal Code Cpmcil Cetificatim#: ,4Z 1 - <br /> ALTERNATE 1 M al l Relation to UST Facility(Check One) <br /> Desi is Name: operator ❑ Fm oy <br /> ❑ Owner 13 � 1 ee <br /> Business Name(ifdlffemnrfrom a <br /> C, Service Teehnicim ❑ Third-Party <br /> Designated Operator's Phone#: <br /> Expvation Date: <br /> International Cade Council Certification#: <br /> ALTERNAT Relation to UST Facility(Check Once) <br /> Designated Operator's Nan c: ❑ F�loyec <br /> ❑ Owner ❑ operator <br /> Business Name of t*fferent from above): ❑ Service Techr cim ❑ Third-Party <br /> Designated Operator's Phone#: 'nation Daae: <br /> Internetio¢e1 Code Council Certification#: <br /> NOTE:THE <br /> AL REGULATORY <br /> WrrHII'13fi DAYS <br /> IN-FORMATION OF THE CHANGE. <br /> D OF NY CHANGES TO THIS <br /> redist for the facility indicated at the top of this page,the individual(s)listed above Will <br /> Designated UST )perator(s). The individual(s)will conduct and document monthly <br /> inspections and annual facility employee training,in accordance with California Code of <br /> ions,tide 23,section 2715(c) (f) <br /> rmore,I understand and am <br /> in compliance ble to underground storage tanks. �t� <br /> ions,and localordinaotxs) PPOF TANK OWNERi iILO tVlNER'S AGENT(Please Print): r rTURE OF TANKR OR OWNaE��R'S AGENT:_ <br /> DATE: of OL(. OWNER'S PHONE#: x O <br /> ZOogt Yvd lt:LT VOOZ/SZ/VO <br />