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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with 1#A1 irP1T`1n�3 <br />Facility Name: VA &t,e Y AO/ U <br />F4# tyfID.#: <br />Facility Address: /(o C, HAPOIIV4, WAYdp:sia <br />S 7pC-�TQ/1J CA � L O �/ <br />tfi rm t�i£ o(Check One) , <br />t� Change ofl�esi�&4 rator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: ZDel . y -q__l <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Karen R. Abbott <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician X Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #:(209)518-4836 <br />International Code Council Certification 9:5266643 -UC <br />Expiration Date: 10/12/07 <br />ALTERNATE 1 (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 (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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 (If different 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 <br />SIGNA' <br />DATE: <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 agy s,html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />