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i 0 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />Facility ID #: <br />Facility Address: <br />Reason for Submitting this Form (Check One) <br />2'Change of Designated Operator <br />!B' Update Certificate Expiration Date <br />Facility Phone #: <br />Desi¢nated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: 7 <br />l e <br />Relation to UST Facility (Check One) <br />❑Owner 13 Operator ❑ Employee <br />❑ Service Technician 19-Athird-Party <br />Business Name (lfdif(%rent from above): '" <br />Designated Operator's Phone G 7 - at' 0 <br />International Code Council Certification #: 900 <br />(ys:s—ei <br />Expiration Date: 1601bi5to <br />ALTERNATE I (Optional) <br />Designated Operator's Name: %,,,, F I V ISS C r <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician t§-"fhird-Party <br />Business Name(Ifdiiferenifrom above): T 1401e <br />Designated Operator's Phone #: _ _ rf0 <br />International Code Council Certification #: S t, (,' 9 (AG <br />Expiration Date: I I 2610 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (/fdi,(jerentfromabove).: <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration 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 Print): <br />SIGNATURE OF TANK OWNER: <br />DATE: OWNER'S PHONE #: <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.ca.gov/ust/contacts/cupa aeys.htmi. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />