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02/01/2006 16:10 2094662740 VANCO PAGE 01 <br /> V rI <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: I "'f C i I - k O Facility IU tt: ,/� C <br /> Facility Address' <br /> S (V 3 7 &L it '� 1� 1�M Reason for Submitting this Form(Check One) <br /> .�� Change-'Designated Operator <br /> Facility Phone#: 2�cj ,�. u .— d ❑ Update Certificate Expiration Date <br /> Desis mated UST ODeI'1+t0r(s)for thip Facility <br /> PRIMARY <br /> Designated Operator's Name: Karen R. Abbott Relation to UST Facility(Check One) <br /> Business Name(lfdifjereni from above).- ❑ Owner d Operator ❑ Employee <br /> Designated Operator's Phone#:(209)518-4836 ❑ Service Technician I Third-Party <br /> International Code Council Certification#:5266643-UC Expiration Date:10/1.2/07 <br /> ALTERNATE <br /> Designated Operator's Name: Relation to LIST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 0: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification b: Expiration Date: <br /> ALTERNATE 2 (Opvtonal) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above)' 0 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone M: ❑ service Technician ❑ Third-Party <br /> International Code Council Certification k: 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(e) - (f). <br /> Furthermore,I understand and 2112 in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> 1 .�9 f/ <br /> SIGNATURE OF TANK OWNER: r <br /> p <br /> DATE: ( ` t .. OWNER'S PHONE#: 20-! — 4 b r V 6 O ,L <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 1S AVAILABLE <br /> AT:www,waterboards ca.g2Lu�goatacts'cuoa aeve.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />