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F GE ei: <br /> Ou'ner Statements of Designated Undergrou:td Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> r„ciiityNs,ne 11FarWA s Ipy (-•a.G, Jq(� Fec+Id+IDA. <br /> ❑ Chinet of Daie+rmtl Operara <br /> Fetitity <br /> �� i C Updnre Cern{ww rxplretion Ante <br /> I)attianilted VST Oeerttor(e1 for tiasFadlity <br /> PRIMARY <br /> DesleaucJ Oxntoi s Nemc. _� /0 _ ¢'..,F Ro.ouan to UST roil My.(CAas 0*. <br /> r BueinW Nan%(! d <br /> {Q's�eMfP•osr phn.y,L h$'1e A�>_rrr� s r O Owner Q Optrnor C 4,nplayec <br /> ❑M.ins;W OpenlmY Phnns$,( rG)_ T4.I • i f�> rE ServlooTeennkiu n lbtrdrs,ey <br /> tmemseional Cats Oourrcil Cern�auan A. S a Y 0 c t f - v c Espk$ttOn DerC Q. I? O G <br /> ALTERNATE 1 Egpoleeeg <br /> rDaiputed Opener'$Nasty: A L u w M t d a .q, IAdhuan to UST Facility(CMA Onto <br /> BuNnars Nana(.{jdfgY+rnlha+a ohnw,l. C Owner O (operator a Employ- <br /> 'lteKnerd Opener's Mens M; .tLlter <br /> Si=Taea Aniren TM-d.•.Piot-yagr -�� <br /> frrcmnetwnsl Cnds Cornell tert�ilei[lun M;A,��� 8acplratlan l7s+c: ,J? -I Y-ore <br /> ALTERNATE3t� <br /> DCd�a$etd OparUor'a Nsata: ,�T3� �tw�e r Raloliae to:;.%T r *ck 0w) <br /> h—ptyi—,yeas'-^N_rn-0(-1jda8iNnlJ.cM sEove/: h r 0 Ownee C OOoruor a Employet <br /> ngseNted OpaMnr•s rho"e: !e!G) -F1 7 - { s S > !' 3e+vttt 7'ecnnip,en Q '1'hird•Pony <br /> immetiaaN Coot Council Certifi.irs inn�wnn.rr,,,_Gtju e..✓ Y,L Espintidn OR.c' l l ' r_•sb <br /> i <br /> I I certify that,for the facility indicated at the top Of this page,tlX individual(s) listed above will <br /> serve u Designated LIST operator(s). The individual(s)will condtut and document monthly <br /> lilcility inspections and annual facility cmployx trainiog,in accordance with Calikir.ia Code of <br /> Regulations, title 23. section 2716(c)- (f). <br /> lRyrthermora,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local otdinaaces)applicable to*NdtTgrow$d storage tanks, <br /> NAME OF TANK OWNER (Pb+ ePrint): CAI IfOrA,)/!i„ C- <br /> SIGNATUREO�^FTANK <br /> lOWNER:G4ItA fU[&iQ+ts sT�►7it�� 'uC' ftciat� S+�v_a-�MAnlAsel) <br /> DATE:_ y� .�-l —D`'�" OWNER'SP14ONEar: <br /> NOTE: i)SUMMIT THIS COMPLETED FORM TO THE LOCAL AGt"ICY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BV JANLARY 1,2Oa THE LOCAL,AGENCY LIST IS AVAILARLE <br /> AT:,yv`+w wrv,J>��bfi'.. r t' +StE�SIiYLhtrJ1• <br /> 2)NOTIFY THE I.00AL AGENCY OF ANY CHANCES TO TMIS INFORMATION WITHIN 30 DAYS <br /> OP THE CHANGE. <br /> V WernEc'?nM <br /> 60 39dd 7 639I1 T8CTCZ8 bE:ET b99Z/6Z/ZT <br />