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Owner StatementIlDesignated Underground Sto:!(A Tank (UST) Operator <br />And Understanding of and Compliance with UST Requirements <br />Fad' Nam <br />(rt N o t N MRRA(r <br />Fadf A7±� <br />W Z <br />Facil' PFacif <br />IReasan <br />for Fomr <br />O of 0 Certificate <br />ration Date <br />othw <br />.� '_=t 'V..� �� 1J ice• Y � � i u � <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br />Designated 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, Title 23, <br />section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br />ordinances) applicable to underground storage tanks. <br />Name of Tank Owner (Please Print): tiTmr SIT 51 t1L4 L+ <br />Signature of Tank <br />Date: OS Owner's Phone#: ) 931- 57181 <br />NOTE: <br />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 AT: <br />www.waterboards.ca.20v/ust/contacts/cuoa a¢vs html <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WI_ <br />JAYS OF THE CHANGE. 1E � J D <br />,;u;l 3 G 2005 <br />ENVIRO[OAENT HEALTH <br />PERM f/SERVICES <br />