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07/12/2013 15:45 FAX 12098589545 SUPER STORE IND 0011001 <br /> 0 RECEIVED <br /> San Jesquis County JUL 112013 <br /> E Street tw CAS <br /> 6AOENVIRONMENTAL <br /> Telephone(2119)4M-342p Fa=(20)4Qk343 HEALTH DEPARTMENT <br /> Owner Statemends Of Designated Underground Storage Tank(UST)Operator <br /> Md Understanding of and Compliance with UST Rcqu wwnLe , <br /> FMWUW Add �` s Faular¢D UP- <br /> it it far&*Mzuwg an w4m(cha&OA0 <br /> C <br /> Fwft]Phn #. 209 O Updit mtW, aDor <br /> Ewimlx <br /> Deamated UST Ocernbods)for this Fscwft <br /> randAARY <br /> 1? IOpmsma'sliame: Rdstiwm to USTF6i(y(C/rc*ciao . <br /> 139140M(V&Vbvlwjkm akw): d Ovmm 0 Opwabr ci nvwyo: <br /> DasiB SPMm#: ❑ 9m.iwTachakjG.n 0 "Itmdpary <br /> I�eramoml Cads Camel(kms(-eYian#: o� FxFiw6ouDsta -'y-�D/Com_. <br /> ALTUMTE I - <br /> w <br /> 4;4 <br /> R se) RolatimbUST F=9ay(Cdr,*owe) <br /> ❑ 0. o Opm sw u� BmPlayc <br /> Saver Tad �o ❑ '11m i-part'. <br /> ALTERNATE 2 (Upp <br /> Ind Opwaim's Na Rehdim b USf FaCWW(C IFI*OWJ <br /> BmhmwNme(Udffmwfi,as atone): - ❑ Owner ❑ Dpn*m ❑ Fmploym �i <br /> Dosi8aaW OpmeWs Vh x: O Sarvim Taebnlotn ❑ 'lbk&ftrfy <br /> t>dewmtim1 Cade COMB Cntifimtkm A: Ude: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTHaM OF ANY[:RANGES TO TM <br /> 94FORMA11M WrfHlN 30 DAYS Of THE CHANGE <br /> v <br /> 1 certify that, for the facility.indic ated at the top of this page,the in&vidual(s)listed above will <br /> serve as Designated T TST Opera tm(s)- The individual(s)will conduct end document rnon&y <br /> f el4 inspections and mutual facility employee teaming,in accordance with California Code of <br /> Regulations,title 23,section 2715(c)-(f). <br /> Ferthermore,I Understand and am in complian"with the regairemeots(statate <br /> regulations,and ln®1 ordinances)applleable to undezWoM d stnrage tanh3g. <br /> NAME OF TANK OWN=(Preaae Prh,* SwPgAg s'Iou s 1 rldiA-sf ie(e <br /> SIGNATURE OF TANK OwNnL <br /> DATE: 1,�. 013 OWNER'S PHONE#:�CA� SS6 - moiag <br /> November 2004 <br />