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Ownew S�atQments of Designated Underground Storage Tank (UST) Operator <br />"..' a�Jinderstanding of and Compliance with UST Requirements <br />a 73 z: cz <br />``'`"Valley AM & PM <br />Facil� N�ii�e; <br />Facility ID#: FA0003610 <br />Facihty Address: <br />Reason for Submitting this Form (check one) <br />16c':�. lfiIng Way <br />StRkto1: -falif . 95204 <br />❑Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />,- <br />Faci Phone #. 209-466-9516--f" <br />Designated UST Operator(s) for this Facility <br />Primary <br />Designated Operator's name: Dan Mcllrath <br />Relation to UST Facility (check one) <br />❑ Owner ❑Operator ❑ Employee <br />❑ Service Technician,UThird-part <br />Business Name: Valley Underground Tank Monitoring <br />Designated Operator's Phone #: 209) 476-1805 <br />International Code Council Certification #:)(X4141012575 Ex iration Date: 11113!2006 <br />Alternate 1 <br />Designated Operator's name: <br />Relation to UST Facility (check one) <br />❑Owner ❑Operator ❑Employee <br />❑ Service Technician ❑ Third -party <br />Business Name: <br />Designated O erator's Phone #: <br />International Code Council Certification i Expiration Date: <br />Alternate 2 <br />Desi rated Operators name: <br />Relation to UST Facility (check one) <br />❑ owner ❑Operator ❑ Employee <br />❑ Service Technician ❑ Third -party <br />Business Name: <br />Designated Operator's Phone #: <br />International Code Council Certification #: Expiration Date: <br />ivoie: 1 nc LUt AL Kr-UULA I UKY AUtNGY MUST BE NOTIFIED OF ANY CHANGES TO <br />THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br />Designatd UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br />and annual facility employee training, in accordance with California Code of Regulations, <br />title 23, section 2715 (C) - (F). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br />and local ordinances) applicable to ungerground storage tanks. <br />Name of Tank Owner <br />or Owner's Agent (Please Print): / is 0 lS76$1� l� <br />Signature of Tank <br />Owner or Owner's Agent:. <br />Date: %C I1 y'jr <br />Owner's Phone #: <br />