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07128/2011 07:50 209466°F18 VALLV ARCO PAGE 01102 <br />E (0" <br />; r <br />JUL 2 8 2011 <br />Owner Statements of Designated Undergrown Storage Tank (LT�auil Undorstaztding o£ and Com►plial>tce , 'th 1 TST +rquirgM, i��-V <br />EPARTMENT <br />1FacilityNnmF' Facility ID #; <br />FaeilityAddtess_ !� Rcason for submitting this <br />.E"orrn (Check One) <br />Change of Designated Operator <br />X Update Certificate Expiration nate. <br />Facility Phone # <br />Designated Operator's Name: ]Karen R Ar>ua.iiz <br />T3usincss Namc Urdifferenl frau above): <br />s Phone #f: (209)'518-4836 <br />International. Code Council Certification #: 8032295 -UC <br />ALTERNATE 1. O tional�� <br />Designated. Operator's Name: <br />Business Name (.(f direni frorn above): <br />Designated Operator's Phone #: <br />#international Code Council Certification #: <br />ALTERNATE 2 (OPdond) <br />Designated Operator's Name: <br />Business Name (ff diereitr from above): <br />Dcsign,ated Operator's Phone #: <br />irrternational Code Council CatiFcation i€: <br />Relation tn i IST Facility (.Cheek One) <br />O owner 0 Operator ❑ Employee <br />o soviet. Technician X 'third -Party <br />Expiration Date. 06/11/2013 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Emplrrycc <br />0 Service Technician i1 Third -Party <br />Expiration Date,. <br />Relation to i i.ST Facility (Check One) <br />0 Owner 0 Opomtor 0 Employee <br />❑ Service Technician ri Third-Part.V <br />l;xpiration Date: <br />1 certify that, for the facility indicated at the top Of this fie, the individual(s) listed above will <br />serve as Designated UST Operator(s). The individuW(s Twill conduct and document monthly <br />facility inspections and ay.nual facility employee trainin , in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (fl. <br />Furthermore, I understand and am in compliance wh the requirements (statutes, <br />regulations, and local ordinances) applicable to and 1,l;round storage tanks. <br />NAME OF TANK OWNER (Please Print): ffCNs� m <br />SIGNATURE OF TANK OWNER: <br />DATE: ` - I OWNER'S YHON)E <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE I. <br />RICSOURC)ES CONTP-OL ROAR13) BY JANUARX 1, 2005. <br />AT: www.waterboards.ca.gov/ust/contacts/cu a agv_s,htrnl. <br />2) NOTIFY THE LOCAL A.GrNCV OF ANY CHANGES T <br />OF THE CHANGE. <br />C <br />L AGENCY (NOT TME STATE WATER <br />LOCAL AGENCY LIST IS AVAILABLE <br />INFORMATION WITHIN 30 DAYS <br />November 2004 <br />