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y <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: !i f ,'L -e— MflRkC-r <br />Facility ID 4: <br />Facility Address: L�A <br />Zak{ bi AKD*k NG LAJA-1 <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: C t -1 g — 60ACUL, <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: Q Relation to UST Facility (Check One) <br />Business Name(Ifdifferentfrom hove): ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: Z-0 – ❑ Service Technician ird-Party <br />international Code Council Certification #: Expiration Date:�j'� <br />ALTERNATE 1 O clonal <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Oodona0 <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierent from above): <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): /V DC K– <br />SIGNATURE OF TANK OWN "p <br />DATE: �1 11I I"I OWNER'S PHONE #: 9�f5 (S ? <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.goy/ust/contacts/cut)a agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />