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FROM : KEN PAIGE PHONE NO. : 209 3336306 Jan. 04 2005 02:49PM P2 <br /> 46� <br /> Owner Statements of Designated Underground Storage Tank (UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nam^ �,���7r!E`� Fawliy Mis <br /> raalay Address: T ... <br /> LOGrFPM rLf� � Reason rar lnGm etingrhs Pcom rChekC', <br /> - - 17 Chm�ge o!Dea;q+atmd Operater <br /> e - P p U Certifiese Expira+ion Oefe <br /> �IaeiRnated UST(laeratorlc)for lois I�kriiity <br /> i PRB4ARY <br /> OCIL-Amd Opemmr's Nsme:.4jAr)e �qc egs�� - Relation to UST F461sty(Check Oaej <br /> 8usiaabs Vame(Ifdt/ki'anrfrowaEato):AI.4»/a / -t owner a Oprrnr n Employee <br /> Designated Orgy's Ptxme a: y -� 4 Li Ip ServlcrTeeitticim �jN�-?zrey <br /> intemmimW Co c Com 6l Certifi&dm sit orz 784.7 ;e- ! EKpir'WM Date: <br /> ALTEWATE 1 f0!ti- Q <br /> Dosignated Opmm s Name: ; Relaaon w UST_FWIfty(Check Orrsj <br /> 8usinesa Ntmx(tld renJfiom shone!: i p owner O oposdor G Employee <br /> Desi[n,akd Operalor'?Phone?• ❑ $Bn:cB technician Cl Drird.Party <br /> LaenatfionW Code Coumll Certification N` i Explratioa Dem: <br /> Y ,�F Z lOdfioaatl <br /> Des4paW Opcmlor's Name; Reladoato UST FadRty(Cheek o»a) <br /> s15if1eSy Name(r7dffem*rf v.abm�J: O Owner C operetm C Employee i <br /> Deaip&d opaques Phmce tl: C Servioc`r=hniclan O Teed-Fahy { <br /> lnt mntional Code Craatoil Cerdfimdoa#: — E�iraGpa Dim: ~—y <br /> NOTE-TBE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> r INFORMATIONWITSBV30DAYS OFT319CHA.NCE. <br /> I certify that,for the Aacility indicated at the top of this page,the Individual(s)listed above will <br /> serve as Designated UST Operator($). The individiW(s)will conduct and document monthly <br /> j fecility inspections and annual facility employeetraining,in accordance with Califbre.ia Code of <br /> Regulations,title 23,section 771 i(c)-(i)• <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage toulm. <br /> ). NAME OF TANK OWNER <br /> j OR OWNER'S AGENT(MIA"Print): <br /> 6TCNATURE OF TANK <br /> OWNATR OR 00M' B�R'S AGENT: 1 <br /> DATE: I'^ 3-VJ Ow74E1'sPBONE9:�3 67.3 <br /> J <br /> Septotaber 2W4 <br /> j <br />