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DEC-.31-20e4 16:36 FROM:MORADA CHFURON 12099316638 TO:46e3433 P.1,2 <br /> ' [9 ❑4 O2: 1Ap <br /> p. e <br /> r <br /> Owner Statements of Designated Underground torage Tank (UST)Operator <br /> and Understanding of and Compliance w th UST Requirements <br /> Facility Nave- 'Mnft?A-T I,k (' {�t�� Faeday lO N: <br /> Facility Addreaa: for SobmitliAt this Fors(Cha'k Por) <br /> 051% N. 1G W fOf k N"CA gs2i 2 O Choogeorposigaaledoperaior <br /> Facility Phaoe A- O t O Update crt ifi [C Ps Irian o*c <br /> Voienated UST Ooerstarts)for+this Facility <br /> PRIMARY <br /> Designated Opmtoes Nstx. Q _jml_KuMAQt.ATA ¢.M,ir to UST Pac111ry lCherk One) <br /> Boaiani N-- e(fdptrene/nom alavaJ Nti42hL ./t�aLLti t ❑ Owaet �i gperator O Eiopw. <br /> Dedgputad Op we,rtwne^ aoq i51 rgu ❑ Se los Twhniebn ❑ Thud-Puny <br /> UAtiaada Code Coameil Cenfeadon 0: Eapirolm Dale: <br /> Aj.TERNATE I O liana <br /> Dnirnattd Opaamr'a Name: Relaiioll to VST Fad*(Chee*0-4 <br /> 6osincu Name((/rl(((eraw/M- houe): O Owns O Oparmr O Employee <br /> Duignated Opcniors".M 0: ❑ Swia Tachnicien ❑ Third-Pcly <br /> trcmati=1'Code Council Crni icutian a: Expir.lien D31e: <br /> ALTERNATE 2 ftiionafl <br /> Dcalymacd Optrste;'s Nawc� Ptution to UST Facility(C7rrck0n4 <br /> awiness Name QrdOrentfi about): O Owrr O Operator 0 Emplayee <br /> DaiENted Opmtoy's Phone r: ❑ Servia Technician O Tlsir"Am <br /> laarmtiotal Code Cmtnait Certification N: { Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTT' IED OF ANY CHANCES TO TFDS <br /> INFORMATION wrToN3o DAYS OF THE CHANGE." <br /> i <br /> I testify 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)WE 1 conduct and document monthly <br /> facility inspections and annual facility employee training,inaccordance with California Code of <br /> Regulations,title 23.section2715(e)-(f). <br /> curuierinore,i.undetsiaaad&ad am in compliance with 4 e requirements(statutes, <br /> regulations,and local ordinances)applicable to undergr#and storage tanks. <br /> NAME OF TANK OWNER - A <br /> OR OWNER'S AGRNT(rteaae hint)^:,-( <br /> SIGNATURE OF TANK ^I <br /> OWNER OR OWNER'S AG � .. <br /> DATE: 11-of G-04 owi s MONS n: 1707 - 94-7 55 <br /> septanber 2004 <br /> aooiaoo� h��i� �a�a aoao "1 son XVJ ZMT ©A 600dIMI <br />