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RUG-06-2010 13:55 Service Station Systems 408 938 8888 P.02 <br /> s <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> .,FacilityName: 'c P.01,1.0 1 Fac4lity1D#: �(a <br /> FacilityAddress: 4,alS h-�eryde.,.,4Reason for submitting this Form(Check One) <br /> ❑ Change of Designated Operator <br /> Facility Phone#; '�U9„ (p_ q3 `Update Certificate Expiration Date <br /> Designated UST Operator,(S) for this Facility <br /> PRIMARY <br /> Designated Operator's.Name: TviL)vviac7 Relation to UST Facility(Check One) <br /> eusp,n Nalpe(lfdifferentfram above); VIC-5' 4�' �.fttM Gj .� ❑ Ovmrr ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 611 �I,r t}Gf fiLServiee Technician Tltirtl-Forty <br /> Intcmational Code Council Certification#: aj (,y _ L((e` Expiration Date: 'I 'z IZ <br /> ALTERNATE 1(Optional)-- <br /> Relation <br /> O tionalRelation to UST Facility(Check One) <br /> Business Name(if dti ferenr fmm above): <br /> [it' }at (M ❑ Owner 13 Operator ❑ Employee <br /> Designated Operator's Phone#: (L-Vb) 1;ill�crvice Technician [Third-Patty <br /> international Code Council Certification#: s52410 —u G Expiration Datc: i 17 11 <br /> ALTERNATE 2 (Op&#41) <br /> Designated Operator's Name: M ��-(tr] ��✓� Relation to UST Facility(Check One) <br /> Business Name(lfd(ffem a fmm above): y0&e •�I+Vf yl ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: service Technician IOK Third-Party <br /> Intonational Code Council Certification . UC Expiration Date: III <br /> i <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 2915(c) - (fl, <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and Inca] ordinances) applicable to underground storage tanks. <br /> �� ` � <br /> NAME OF TANK OWNER(Please Print): IKe r� I� <br /> r 0;x AGG _ <br /> SIGNATURE OF TANK OWNER: /U <br /> DATE: _ ll'l�JD OWNER'S PHONE#: `t 1b- 373- 4e3Q <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.waterboards.ca.pov/tist/contacW(;una agys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THT$INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> TOTRL P.02 <br />