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�- N101 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: rC I Facility ID#: <br /> Facility Address: 11535 eSCf1IJGQ Q Reason for Submitting this Form(Check One) <br /> Tro.G 4 Rf Change of Designated Operator <br /> Facility Phone#: 7j 3 • 1 36 ❑ Update Certificate Expiration Date <br /> Desitrnated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: W CWRelation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): ,T ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:I AX Service Technician ❑ Third-Party <br /> International Code CouncilQ <br /> Certification#: U O VD . VC Expiration Date: Z.- <br /> ALTERNATE 1 (Option! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii erenr from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:PM) `Z• 23 2, t)�ServiceTechnician ❑ Third-Party <br /> International Code Council Certification#: 3ZQ Ilj w Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service'fechnician ❑ Third-Patty <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE 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 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 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print): I I! l� I� i'Let, I rllt <br /> SIGNATURE OF TANK <br /> OWNER OR OW/NER' AGENT: / <br /> DATE: S PHONE#: X'70 <br /> September 2004 <br />