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xN �tv N co <br /> Doo <br /> W <br /> Ownet Statements of <br /> Designated Underground Storage Tank(UST)Operator O j w m <br /> v and Understanding of and Compliance with UST Requirements ~' �* D <br /> 7 <br /> 77 <br /> CD Facility Name: ��$• Q <br /> Facility Address: 7`e' _ a$ Facility ID#: i Z <br /> O S JfC7�yy� r?a t r~ Reason for Submitting this Form(Check One) O O O <br /> /2 O5 <br /> O Facility Phone#: ❑ Change of Designated Operator CA W <br /> ❑ Update Certificate Expiration Date 11 <br /> - --i <br /> Designated UST Onerator(s)for this Facility cD <br /> O <br /> M C� � <br /> = PRI1vL4RY <br /> C � � <br /> (n0 <br /> Delia sled Operator's Name: „/ -s• � � � <br /> U L Relation to UST Facility(Check One) p Z <br /> Business N _ � <br /> Name(Ifd�erent from above): <br /> �m zen-/ �'/ ❑ Owner ,Operator ❑ Employee � <br /> Designated Operator's Phone#: 2 <br /> v_ ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: C:).. <br /> d <br /> �'7 Q Expiration Date: 7 7- <br /> ALTERNATE 1(O tions! <br /> Designated Operator's Name: T <br /> Relation to UST Facility(Check One) CD <br /> Business Name(Ifderent from above): O CD <br /> ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: a. <br /> ❑ Service Technician ❑ Third-Party t~ <br /> International Code Council Certification#: <br /> Expiration Date: Qn p <br /> ALTERNATE 2 (Optional) Q <br /> Designated Operator's Name: M <br /> Relation to UST Facility(Check One) 0 p <br /> Business Name(Ifdfferentfrom above): <br /> ❑ Owner ❑ Operator ❑ Employee � � � <br /> Designated Operator's Phone#: Q” <br /> ❑ Service Technician ❑ Third-Party CA <br /> International Code Council Certification#: <br /> Expiration Date: O <br /> CD-•C q <br /> t� <br /> Flil t,for the facility indicated at the top of this page,the individual(s)listed above will o <br /> signated UST Operator(s). The individual(s)will conduct and document monthlyections and annual facility employee training,in accordance with California Code of <br /> ,title 23,section 2715(c)e,I understand and am in compliance with the requirements(statutes, tt�gaons,and local ordinances)applicable to underground storage tanks. c <br /> NAME OF TANK OWNER(Please Print): O <br /> SIGNATURE OF TANK OWNER: <br /> DATE OWNER'S PHONE#: <br /> rp <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 o <br /> AT:wwwmaterboards.ca. ov/ust/contacts/cu a as s.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. n O 0 <br /> 7� iz <br /> November 2004 <br /> o <br /> cn (D CD <br /> 0 <br /> -U w <br /> tv ,� <br /> CD <br /> FD w <br /> O a v' <br /> CD <br />