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JUL 06 2017 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator ',LTH <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: U, /Z Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> $ay os tnzl E AVL ❑ Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Overator(s)for this Facility <br /> PRIMARY A a cJ b6ar <br /> Designated Operator's Name: (v D f CA L P ajet>n 1.1'1 G Relation to UST Facility(Check One) <br /> Business Name(If diiferentfrom above): !G p etPoleika, mC ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: a 5 — D Cl Service Technician 0 Third-Party <br /> International Code Council Certification#: 2, - C Expiration Date: <br /> ALTERNATE 1 O banal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferenrfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> I certify that, for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c)- (f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Ln 11A e2 t <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 2(nf �J f9( , OWNER'S PHONE#:(�©rJ <br /> NOTE: 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 <br /> AT:www.waterbouds.ca.gov/ust/contacts/euva agvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />