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JUL 13 20(19 <br />ENVIRONMENT HEALTH <br />Owner Statements of Designated Underground Storage Tank (UST) CFIWERVICES <br />and Understanding of and Compliance with UST Requirements <br />ity Name:�, tnrt✓rr� -% �K Xe k� Ya/0,21 Facility ID #: <br />Phone #: <br />Reason for Submitting this Form (Check One) <br />0' Change of Designated Operator <br />Designated UST Operator(s) for this Facili <br />Certificate Expiration Date <br />PRIMARY <br />Designated Operator's Name: 2'4104-4 Q I en Relation to UST Facility (Check One) <br />Business Name(Ifdierentjrom above): " o ❑ Owner ❑ Operator Cl Employee <br />Designated Operator's Phone #: 9S/_ _ ie •O ❑ Service Technician <br />Third -Party <br />International Code Council Certification Expiration Daze: <br />Designated Operator's Name: —R, „t C e f Relation to UST Facility (Check One) <br />Business Name (Ifd�ererttjrom above): ^vl l/�✓1 ❑ Owner Cl Operator ❑ Employee <br />Designated Operator's Phone #: ❑ Service Technician <br />cLQ G 6 3/Third-Party <br />_International Code Council Certification #: s <br />r•(y—Lt C Expiration Date: Q/7/' %4r5t ri <br />Designated Operator's Name: W 1, ( t c r5 Relation to UST Facility (Check One) <br />Business Name (Ijdt//erentjromabove): ❑Owner ❑Operator ❑Employee <br />Designated Operator's Phone #: - ❑ Service Technician WThird-Party <br />International Code Council Certification #: cid rl `i _ ( G Expiration Date: <br />-2/1n/1n11 <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 Print):: e5e,el% ,�i ryytDnS <br />SIGNATURE OF TANK OWNER: <br />DATE: —1�/�Bq OWNER'S PHONE <br />NOTE: t) 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.ca.gov/ust/contacts/cur)a an�ys html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF TH E CHANG E. <br />November 2004 <br />