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Owner Statements of Designated Underground SAPR 2 9 2009 �T f AjfF Operator and Understanding of and Compliance wit bents Facility Name: '9 I n r�-�-P_�. � uFacility ID#: Facility Address: -` ' -- 1 J 1= ,,�GS£m t {�v,e Reason f'or Submitting this Form(Check One) IYlGt+N}E Change of Designated Operator 1•auh[y Phone.#. 20 S --7 ❑ Update Certificate Expiration Date Desienated UST Operator(s) for this Facility PRIMARY Designated Opendor's Name: ' Relation to UST Facility I('heck One) Business Name Qf'tti)frentlromabove): li0.6(e 0 wee ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: zoq — 3(O �( SeniccTechnici:m ❑ Third-Party Intemational Code Council Certification#: J 5 ra D — ur Expiration Date: ALTERNATE 1 U 'onal _ — r D Designated Operator's Name: Relation to UST Facility(Check(jine) Business N.vne t J rliJferentJiom chore): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party Imemational Code Council Certification#: Expiration Datc: ALTERNATE 2 (Optional) rIntemational Operator's Name: Relation to UST Facility(Check One) me(If diJJerx nt from above). ❑ Owner ❑ Operator ❑ Employee DesignatedOperator's Phone#: ❑ Service Technician ❑ Third-Party Cafe Council Certification#: Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please Print): I SIGNATURE OF TANK OWN I Z /,G J OWNER'S PHONE#: _ZGe( DATE — �{}5 -77J4 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1,2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION W(THIN 30 DAYS OF THE CHANGE.