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Owner Statoments of Designated Underground Storage Tank(LIST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> raality Nares - gx H')FGvua / Facility ID a: <br /> 'Faclliry Addnis: / RMVOD Rv Suym tiing dtil Farts(Chrck Orn) <br /> Change of Dwigaamd Operaror <br /> Fw1ky Phone#: X2.00 ❑ U12 Cornets Rxpirnticn Date <br /> Designated UST Operators)for this Facility <br /> l�ttrMnxev _. .. . <br /> Designstc4 Operator's Nam: a,V�� Cr�< • fry Rdntion to USTF=411ty(Uvr •0 ) <br /> awlnase Namo(lfdyfary<ntfm be-o-- A-Hav-da- •`r69T O Oma 0 Opemtor ❑ LNptoyeo <br /> Dniputed Opamtor's Phoac k _.• ZOg it L` ^ ( Z Cervico Technidm ❑ 11LIId-Party <br /> Intematinnal Cnde Cnundl Crmifrcatlun N. �� '37' ltxpim6ap Aaro: �j� $ . <br /> ALTERNATEI 602primfUl <br /> Dmignaled Opmtor'n Nam; -,-7 lye', Q„ R4a6M to US'T PwMty(Chw.kOnc) <br /> Au hmm Name(jfd(Q'nentlrom above): `��Ge.K1� a Owncr 0 Opvatar ❑ lImptoyea <br /> Drsipnotcd Opcmax's PhoneiVz ZbC/ -7 i t Swice Tmhniclan D 7hird-Party <br /> _. ... Y_( a.._G.: - <br /> ineematicnalftdeCouncilCunlllmdoa#: V—QC _ Bxpirartoa Does A2 5 Lls. <br /> ALTERNA7'k:2 (Oprirrael) <br /> Dr ,metal Oprmha's Name- Pulgian to UST Facility(C4A Onr) <br /> Auainum Nome(yJrl((jareMjraM rdmvs�: ....^ .�-.- .....^ ❑ own" a Opemmr ri runployee <br /> nesiga fed Opaamr's Phone f: j{ Scwice Tcdmi6iaa ❑ Third-Pa"y <br /> Imetaational Gxlc Cmmdl Cedtrcation#; pxpiradea Darn; . <br /> NOTE:THE LOCAL RIMLATORY AGRNCY M UST RL NOTIRIED OF ANY CHANGFS 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 Operstor(s). The individual(q)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)-(1). <br /> Furthermom I understa7ad and am in compliance with the requirements(statutes, <br /> reguladons,and local ordinances)applicable to under-ground storage ks. <br /> NAMEOF TANK OWNER(Pleaw!'tint): f <br /> SICNATURF OF TANK <br /> OWNER: <br /> DATIt: _oL^_!• / OWNE'R'S PHONE 9:( co 71S�' O/' X3r9 <br /> Novcrnbor 2004 <br /> E00 d BO[089B60Zi 'aN XVd 'HM SS31 MA 0003 WV H:90 NOKAGOZ/61/92d <br />