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FROM :B.Z.5ERUICESTATION MAINTOCE FAX N0. :916 371 2540 10pr. 22 2005 10:40AM P4 <br />01/10/2005 x.0:36 20936976/3 wiNE COUNTRY PAGE 91 <br />r <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understandiniz of and Comnliance with UST Reauirements <br />Facility Nemo: t Facility CD #: <br />Facility Address: Reason for Submitting this Form (Cheek Ona) <br />'' ()�m' Change of Dealgnitted ONrator <br />Facility Phone #; pj C Update Certlflcate Expiration hate <br />l e�W,d -?ST Oyersto1W K tbij Facility <br />reuraainv <br />Designated Operator's Name:- <br />Relation to UST Facility (Check Otte) <br />❑ QVYt3er ® i)perettor ❑ En1p10yet <br />Q Service Ttu:hniaian xThird-Party <br />Business Nano (lfdifferenl from above): <br />4 <br />Designatod Operator's Phone k: <br />j e f i <br />Internaticatal Code Cotuxait Cartiticativn h; it <br />Expiration Bate: <br />XU)JERNATE I anal <br />Dasignmted Operator's Nwo: Relation to UST Facility (Check Once) <br />Business -Name (!f dtj9crenr)Mm above): 0 Owner U Operator ❑ Employee <br />Designated Operatur's Phone t!; D Servioe Technician n 'rhlyd•p" <br />International Cole Council Certification #: Expiration Date: <br />A1,1z"nnitz (UDUOUNJ <br />Dcaignated Opemtor's Name: <br />Relation to UST Facility (Check One) <br />�v`'t�evliEi' _: a i�poirator" 7�.Eni�loyoe . <br />0 Service Technician 0 'Chir$ -Party <br />13:+i4lh�ss:k�la�ma'F,ffd�rrQutj�ro+n:al�ovHj: _ .,.,. ' ;>; _ <br />Designaai Operator's Phone #: <br />lnta"donul codo Caused Certlficatkm fit, <br />Expiration Data: <br />NOTE. THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANCES TO THIS <br />INFORMATION W1TIJEN 30 DAYS OF THE: CHANGE. <br />1 certify that, for the facility indicated at the top of this page, the individual(s) listedabove will <br />servo as Designated UST Operator(s), The individual(s) will conduct and domment inonthly <br />facility inspections and annual ;Facility employee training. in accordance with California Code, of <br />Regulations, title 23, section 2715(c) - (f), <br />Furthermore, t understand and am in compliance with the requirements(statutes, <br />regulations,. and ioepa ordinances) applleable to underground storage tanks. <br />NAME OF TANK OWNER p, <br />OR OWNER'S AGENT (Please Print); <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: T <br />DATE: OWNER'S PHONE #: O1?— <br />September 2004 <br />