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07/24/2013 11:12 209529 HOYETT WAREHOUSPAGE 01/01 <br /> 07/24/2013 11:12AM 209 02 QUICK AND EASY ?AGE 01 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> facility Name:quid.&Easy Fund Mari FacilitR3#- <br /> Facility-Address: 823 F Yosalrim ave Reason for submitting this Farm(Ck d One) <br /> Manta&CA.95336 Chante of Designaard Operator <br /> Facility Phone a' ! k Cipriazc CcrtibcaSc Expiration rate <br /> agiggated UST O e s for this FAcility <br /> PRIMARY <br /> Desi®aw operator s>raetc:Kam R Arnsiz ! RC{ia'ien to U�r Facittty(t".'heck OW) <br /> Busln=Name(Ij&O-csenrJrona6o e): 0 opamror O fimplovee <br /> Iksi_saated opamaez Phan&c(209)518-4836 1 ❑ Service Twhowan X Thant-Parn <br /> Imermdibant Coda Council Cet6rrcadon 3 8032295-UC enpimtion Due.05/31/2015 <br /> A1.T1EkN.47E 1 lanai <br /> Designated Orrawor's Name: Relation to UST Facility(rhook Om) <br /> Business iti=UfdifferewPam abanm): 0 Otma a Operator O EMPthpa <br /> Desfgnmod Operatoes Phone f: 0 Service Tmbnicim 0 third-party <br /> g[ntemadonal Code Coamil(ertiGeation g: Expiration Date, <br /> ALTERNATE3 ftdaxal) <br /> Desrgnateed bpenWesNamz: Relation to tJST Facility(Check One) <br /> basun Nam¢(!j'dyjers aJrom abwa)= 0 Owncr 0 operator 0 EA%00yac <br /> lkstgmtedOperetaYsl'Itor>z;: 0 Service"recimieiaa 0 Third-Party <br /> tntanationei Code Cv 00 C40%=60n C Expiration Date <br /> 1 certify that, for the facility indicated at the top of this page,the individual(s)listed above will <br /> serve as Designated LIST Operator(s). The itxlividasai(s)Nvol conduct and document Itl0nthly <br /> facility inspections and annual facility employee training,in accordance with California Code of E <br /> Regulations,title 23, section 2715(c)-(f). l <br /> Pbrthermore,I understand and am In compliwlce wfith the requirements(slatutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> I NAME OF TANK OWNER MewPrioq: � tN'CiJ2-ES L C. <br /> i SIGNATURE OF TANKOW,-aR: OF2� P�T�OI.E'UtM 1I�•TI112�7 1'l`�' <br /> DATE:^07/2.3/13_ OWNER'SPKONE#*; 06 <br /> NOTE: 1)SUBMIT TIM COMPLETED FORM To THE LOCAL AGF-T4CY(NOT THE STATE NATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2o0s.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:wtuty,N'ntCr60'drdsy, r..�trcriaamaetc�cuoa aces tum;. <br /> 2)NOTCHY THE LOCAL AGENCY OF ANY CHANGES To THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />