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Owner Statements of Designated Underground Storage Table (U ) Operator <br /> and Understanding of and Compliance with UST Requirerni�� 0 2004 <br /> Facility Name: `j �.•� � ,� � Facility a)#; <br /> Facility Address: Reason for Submitting this Form(Check ore) <br /> 6,4 >P Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facilit <br /> PRIMARY <br /> Designated Operator's Name: � �,,•' � rRelalion to UST Facility(Check One) <br /> Business Name(If different from above):s� <br /> wner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: eou• s ] • A ervice Technician �b Thir�l_part,,. <br /> International Code Council Certification#: 50—L t( (Pati 2• u v Expiration Date: r7 1Az. <br /> ALTERNATE 1 Q tional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: d Service Technician 0 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 different from above): 0 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> international Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES 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 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 /> Reg'llationc, titles ? cac,f;on 2715(,) _ r <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 <br /> OR OWNER'S AGENT(Please Print): /►tee <br /> SIGNATURE OF TANK <br /> - <br /> OWNER OR OWNER'S AGENT: <br /> DATE: / -f,/(� / �/'"� OWNER'S PHONE #: 17D7Z <br /> September 2004 <br />