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1ECU UU i V lV GLV 4L <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 2 0 Facility to#: <br /> Facility Address::, tt_V Reason for Submitting this Form(Check One) <br /> 13 7 () tL04 -N ❑ Change of Designated Operator <br /> Facility Phone#: 2- O q- S 9 9- 7 10 O ❑ Update Certificate Expiration Daze <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: O e 6"rJPARMT Relation to UST Facility(Check Ow) <br /> Business Name(Ifdiereni from above): it p Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 3-(j 3KService Technician ❑ Third-Party <br /> International Code Council Certification#:5-2-S Z S 4 o- U C Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: 6QA j>.y(J,/Qe (H Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ({' R,y/6!(M ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: yOq^ o 3 63 ae Service Technician ❑ Third-Party <br /> International Code Council Certification#: , ,2 f0 t/S/ ^ 4 G Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: LEx ,"a <br /> UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Technician ❑ Third-Party <br /> international Code Council Certification#: 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, 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 Prin—t)-��S E F T SISI 6 '1 <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 10 0 2 -12-- OWNER'S PHONE#: l - 5-7 q 01 4 <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.-u.u1n:ust/eontacts/cups aevs.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />