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•a2ikuL 15. 2011111 : 00AMy887340P KAREN ARNArz No, 0634 PL-6 e3/e7 <br /> jUL 15 2011 <br /> Owner Statements of Designated Underground Storage Tarok(US Operator. <br /> and Understanding of and Compliance with UST"Requirements <br /> Facility Name 11 FactMityID#: . <br /> Facility Address: (o1b � p�'2� ReaSoaforSubmiaingthisForan(CJaeckana) <br /> Change of Oesigasted Opmatot <br /> Facility Pdone:R X Update CertlOcatc Eupvatiop POto <br /> pais ated UST Operator(s) for this Facility <br /> PRIMARY <br /> Desigtwifd Opemcor'a Name:Karm R Arnaiz ROlation to USTFacim.(Check One) <br /> sudne5s Name(.jld(p&renifrom abow): O Owner ❑ Operator O t3Mp10yea <br /> Dwigaated opair's Phowe H_ 209) 518-483K [I smi«Technicis,a X '[hitd-ratty <br /> a <br /> ialemalional Code Council cesdsration#:8032295-UC Upinaion Dar:06/11/7013 <br /> ALTERNATE 1 O tin .. .-- <br /> DmPatedOp.arW"sName: � V. ROletiontoUSTFacility(Check Oae) <br /> Business Na b(j/d(f"aantfrmnoboue): --. ❑ Owner ❑ Operator Cl Pmploya <br /> AesigltatedOperator'sFhone#: ❑ Servi"Teemician ❑ Tkdrd-Petty <br /> tilntematiottal Coda C0Mcii Certification#: 6xpiragonPI <br /> ALT ATE2 (Oprtoad) — <br /> Deslgnatad Operstors NaMe' Relation to UST FOoiiity((/heck One) <br /> Bu4nouNeme(jfdtff9renrfi-0))above): a Owner 17 Opccaror ❑ Employ= <br /> Desigaa[ed Operator's Ph0000! ❑ Service Ycchniclaa tl Tbird•Patry <br /> Inlemational Code Council Certification 4! Expiration Dari: <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). Tie individual(s)will conduct and dom went monthly <br /> facility inspections and annual facility etnployeetraining,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(Please Print)- <br /> SIGNATURE OF <br /> rint):SIGNATUREOF/TANK OWNER: <br /> DATE:-///4/ I O'WNIER'S PI[ONE 4h <br /> NOTE: 1)SUBMIT THIS COMFLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WAT15,R <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005,THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.wboards-c&gavlu-st/contactalcnDa sffv1-kW. <br /> 2)NOTIFY THE LOCAL-AGENCY OF ANY CHANGES TO THIS INFORMATION WrMIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />