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+ : KEN PAIGE PHONE NO. : 209 3336306 Jan. 06 2005 03:07PM P1 <br /> It t4 u4 IOU ARIA <br /> ,,qop.. ,,,,,,.,,���•'' 14 b 3�-4 3 Post-it' <br /> -tie 7671 oa1� , , �„gip,► <br /> t Te E �1 'IS Rom f <br /> ( + CO/Dept. Co. <br /> phoria a P1rone <br /> Fex 1_ _ F:ixk <br /> owner statements of I 1V Y (v <br /> l <br /> anti Y;nd�s",axu <br /> f4citi(vNmm: ~-T ...G2E�.t�t 'UJ ---------- <br /> faaliq'rD <br /> I rarollty Addra�: i Rnastm Cor S�rottingdEic Form fClxak C+wJ <br /> +�oraeeis d dOpwaW <br /> ffpciEty Phone,* 202 5,37-4-Cz+3 — o Update Ce df cma BYtameson lie <br /> tlwlnnntpd UST Oawrt'ator(sa ful:01h1ma <br /> Y -- <br /> DcaiBut+d Omawr'a Nano:A1lX Rr AR/ Rsteam 0 UST Faoiiity( rck One) <br /> emdwaVamew .l�extJmat�wsJ: .wit/« Owner 0 open in Pa cya <br /> omawe3 ph I <br /> Daaigaetad n k: Y a Servkr Tech:leien 1D�T<dnYPu(r <br /> httamedoltd Gude Caunei)CwH5eatlam h: z - F PirKim Date: t e—tfi,O b <br /> AT 40 <br /> UamiBnatrd ODa •r''��'+a° P.alatbn w 7J9TFedli1y(Ck44t One) <br /> Bt,akar6 Neem(1fdfferaat JSam abav).�:.--_ ❑ Owm. D Opwgbor 0 @mployaa <br /> Dmv=d Opecaaor's Ph=N: C C1 FhW_PjF ' <br /> Irtm+diots3 f:odeCounclt Cerliflctll0h�: I E'.�-OCPs DaL•: <br /> D,,jV mod OpaxWp Nanny aemdeato UST Fftditiry(Ckck OW) <br /> susi,+ety Nmna(1lIro+a edetic:; ❑ Owner tl Optrdmx C Employes I <br /> DaigNbd <br /> 0 <br /> parnma'9 FhW4 f: _J C7 Scn ix TcvFrj dap q 7hi.d-Aaty 1 <br /> Imast+ttloeal CodetXnatai!Carhfloaticn*: I Expi^etioa Data <br /> NOTE,TIE LOCAL REGULATOitY AGENCY MUST BE NOMED OF ANY CHANGES TO THIS <br /> INFOMMA-nON wrnM 30 DAYS OF TNF.CNtA.NGE. <br /> i certify that, Por the facility indlcatad a<tbc top of this page,the individusi(s)listed above will <br /> serve as Desig:mted UST Operator(s). The individual(a)will conduct and document monthly <br /> lhzllity Inspections and armusl facility e:nployeetraining,in accordance with California Code of <br /> 1 Regulsdons,title 23,section 7715(C)-(f} <br /> Furthermore,I anderatand sad am in colnpllance witb the mquh cmeats(statutes, <br /> regulations,snd local ordinances)appbeableto undergreQad storaWtanks. <br /> �.. I <br /> NAMROFTANIC OWNER <br /> O$OWNEWSAGENT <br /> i SIGNATURE OF TANK v <br /> -71 l <br />' 7 I <br /> I _ i <br /> gCp1zC�.i1aC GL'4" <br />