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D_ 6' <br />4 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: L'— E 7% ,v - C- o - xi A A? T <br />Facility ID #: N . Jj 3 <br />Facility Address: s' q y N (,PA.•7 c/,y(z tT U <br />i/219 e V CA 9 S3 12L <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />A Update Certificate Expiration Date <br />Facility Phone #: .7 p q - S .73.0 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Do et - o l l E S 0.v <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician J1 Third -Party <br />Business Name (If different from above): C 4 A?W <br />Designated Operator's Phone #: Jof- .i3 7 LG G <br />International Code Council Certification #: s',� y ` _ u C <br />Expiration Date: . - O <br />ALTERNATE 1 (nntinnal) <br />Designated Operator's Name: p 4? _ -µ s <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Q, Third -Party <br />Business Name (If different from above): C 4 1? y A H r /.v C <br />Designated Operator's Phone #: 09 - S.?ti 'i 6G G <br />International Code Council Certification #: sac/ / S 5- <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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 <br />OR OWNER'S AGENT (Please Print): <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />Z/-1 T4l,+N f/,t16 <br />DATE: /,2 - a2 3 -o 4/ OWNER'S PHONE #: 0?o,9- k 33 - 3111d, <br />September 2004 <br />