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a.. <br />..04 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: "'1'f G 6 <br />Facility ID #: <br />Facility Address: <br />ZY3 'e . /IW'Pona A d 6A <br />Reason for Submitting this Form (Check One) <br />`4 Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />FacilityPhone #: CZO y Z S774 <br />Designated UST Onerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: L e i rnm o <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician ❑ Third -Party <br />rR <br />Business Name (If Tiff nt from above): A T fa rd 4, • .3 •�- <br />--re <br />Designated Operator's Phone #- (ZOq) r] . Q 11 Z <br />International Code Council Certification#: .5 2y q l l y ,.y,Ji,.. UO, <br />Expiration Date: . i O?_ <br />ALTERNATE 1 f0wionan <br />Designated Operator's Name: 'Z '� NC /�, N <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />Service Technician ❑ Third -Party <br />Business Name (ifd�erentfrom above):cc&CIVA-A_ <br />Designated Operator's Phone #: 7-0ct —7'Y _ <br />International Code Council Certification*. 5�a3:7-Z _ k�_ <br />Expiration Date: a 616)g <br />EZ <br />Designated Operator's Names i��j \ /$ <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />l� Service Technician ❑ Third -Party <br />Business Name (Ifdiff entfrom above): V- _ E <br />Designated Operator's Phone #. 20 4/ <br />International Code Council Certification #: a —� _ <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 <br />r, <br />SIGNATURE OF TANK OWNER: <br />DATE: // % — 0 " C/ OWNER'S PHONE <br />r <br />November 2004 <br />