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FE8 0 6 � <br /> 2007 <br /> Owner Statements of Designated Underground Storage Tank (U$IfJJIQRep,Cor I <br /> and Understanding of and Compliance with UST Requiremifift /rFR�HEA HEALTH <br /> Facility Name: � CCS�UieS (J 1G• Facility ID#: <br /> FacilitytA ddnr ss: El Reason for Submitting this Form (check one) <br /> nJ1 <br /> 1 C �LI I� t zz Change of Designated Operator <br /> 1� ,(�� Cil �� rS� date Certificate Expiration Date <br /> Facility Phone #: Z M\ <br /> Designated UST Operator(s) for this Facility <br /> Primary Cell Phone (209)`649-8956 <br /> Designated Operators name: Dan Mcllrath Relation to UST Facility(check one) <br /> Business Name: Valle Underground Tank Monitoring ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone#: 209 -475-0620 ❑ Service Technician ® Third-party <br /> International Code Council Certification #: 5246558-uc Ex iration Date: 11/11/08 <br /> Alternate 1 <br /> Desi nated Operator's name: lRelation to UST Facility (check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: 10 Service Technician ❑ Third-pa <br /> International Code Council Certification #: Expiration Date: <br /> Alternate 2 <br /> Designated Operator's name: Relation to UST Facility(check onib' <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-pa <br /> International Code Council Certification #: Ex iration Date: <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br /> THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> 1 certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br /> Designatd UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, <br /> title 23, section 2715 (C) - (F). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances)applicable to underground storage tanks. <br /> Name of Tank Owner 1< <br /> or Owner's Agent(Please Print): J O n l 1��VA61rw 5 <br /> Signature of Tank <br /> Owner or Owner's Agent: <br /> Date: *0 <br /> Owner's Phone#: p�Jp-8S�' 336� <br />