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fS 04 02: 18p • r - _ <br /> Owner Statements of Designated Underground Storage Tank (UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FKiIi:Y N,nYc f.eility ID+M: <br /> FOaiiliQ�7y-A�Oapteu: Fl`/s �.. j.j. . - ReeWafar Svinail[inE FvPv e0aa) <br /> . /17� //>,.. - '(/•—._7 ' Ila/ i P C2imgevfDcei`&-Acd0pvw <br /> FtelGry MnmA: 9 a to Cenifium Bx U dan one <br /> i s to f0 this I <br /> rrztlllARY &Joke 10 UST FaeU:ry(CAeek One) <br /> Derteoned Operseert NetIK: f%` y _ <br /> amlmtc Name(/l�r.,(Frtn!lrorn onovpc - a Owner DSr o Employee <br /> Oni®'ned OperMej Menne 1t O Saks Teebwdia a 7ree.Fsry <br /> ( - 1nlenatlaltll Code Council Cardficadva a: tYpYallall INA'. <br /> un <br /> A TERNATE t O sewn <br /> DetitA7ud Openlx'e Nxvr. Relaliva tv UST Fadih"rylCh.dlO+W <br /> ttmiatrs Nine{Ij`o//mnrJrom ahavd; a OwKi O Opar.br O Employee <br /> [kligatled Opcnters Fhoa a: Sorvke Technician a Thild•paryatDnr.Pxp'v.ian <br /> 'We, :lMernatiaaal Oede Covxil CenifR <br /> ALTF"ATE 7 fUpavnap <br /> Detigaated Optr+tat'r Nmna: RdlaUvn to U57 FaciEry(CMrkOnrJ <br /> 8miaeJa N,ma(//d/j�rsntjrom apwe). (3 Owmr a Ope w O Rmployee <br /> DalOrtlod Oper+tot't PftOrc/: a Servs¢Tc Miemlt P 7hit6FAM <br /> 1130=Nlioatl Cala C.-Until Calldiduion N: IAtpml"roa Dale: <br /> NOTE.TM LOCAL REGULATORV AGENCY MUST BC NOTIFIED OF ANY CHANGES To TMS <br /> INFORMATION WITflnV 30 DAYS OF"M 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 Opemtor(s). The individuals)will conduct and document Monday <br /> fsoility,inspections and annual facility employee training,in accordance with C41'fornie Code of <br /> Regulations,title 23.section 2715(c)-(f). <br /> Furlhermore.I understand and am in compliance with the requireenents(statutes. <br /> regulations,aad local ordloaace3)applicable to underground storage tacks. <br /> NAME OF TANK OWNER - AL1 <br /> OR OWNER'S AGENT(Pleuro Print): <br /> SIGNATURE Of TAMC ' / <br /> OWNER OR OWNER'S A � <br /> DATE: p• .- o PRONE 0: 707 - 7*-) z 9 55 <br /> st embe,2004 <br /> aoonoq ZMT o& aooaisziar <br /> X00/ZOOS AEHNI9 DGIN KVO 9090 6H 60Z XVA MZT NOW ROZIO/10 <br />