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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: f Facility ID#: <br /> Facility Address- // ��/� �� Reason for Submitting this Form (check one) <br /> Gv. y Change of Designated Operator <br /> Update Certificate Expiration Date <br /> Facilit Phone #: iC/ 2 <br /> Designated UST Operator(s) for this Facility <br /> Prima <br /> Desi nated Operator's name: Dan Mcllrath Relation to UST Facility (check one) <br /> Business Name: Valley Underground Tank Monitoring :::]E]Owner ❑Operator ❑Employee <br /> Designated Operator's Phone#: 209 649-8956 1171 Service Technician U Third-paqy <br /> International Code Council Certification #: 5246558-uc lExpiraticn <br /> Alternate 1 <br /> Designated Operator's name: Relation to UST Facility (check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification lExpiration Date: <br /> Alternate 2 <br /> DesicInated Operator's name: Relation to UST Facility (check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: JE1 Service Technician ❑ Third-party <br /> International Code Council Certification #: I Expiration Date: <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br /> THIS 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 serve as <br /> Designatd UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, <br /> title 23, section 2715 (C) - (F). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances) applicable to underground storage tanks. <br /> Name of Tank Owner �//�� <br /> or Owner's Agent (Please Print): /S q / ,/)2//[ (N�t3 <br /> Signature of Tank <br /> Owner or Owner's Agent: <br /> Date: �a / ez 7 Owner's Phone#: & 9- 59 <br />