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07/10/2013 14:42 8387674 EMILS PAGE 01 <br /> RECEIVED <br /> JUL 11 2013 <br /> --. Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST RequiremEWIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Facility Name!Emil's Food Mart Facility ID#: <br /> Facility Address: 1405 California Street Reason for Submitting this Form(Check One) <br /> Esealon,CA.95320 Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Desienated UST ODerator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> 13ustne33 Name(if d&rent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209)5184836 ❑ Service Technician X Third-Patty <br /> International Code Council Certification#:8032295-UC Expiration Date:05/31/2015 <br /> ALTERNATE 1 O ions! <br /> Designated Operator's Name: Rclatieo to UST Facility(Check One) <br /> Business Name(Ifdi,(ferentfrom above): ❑ Owner D Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If diifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Farty <br /> International Code Council Certification C Expiration Date: <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,T understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): d YYl <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 07/1.0/13 OWNER'S PHONE#: D <br /> v <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.$ZQVZUSt/contacts/cupa lles.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />