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May 26 09 10:24a Reliable PetroleumA <br />209-845-8953 p.2 <br />r <br />Owner Statements of Desi <br />ted Underground Storage Tank (UST <br />Operator <br />and Understanding, <br />and Compliaince with UST Requirem <br />is <br />Facility Addrms: R <br />1-3'1-Z� i <br />Form Wherk Ona) <br />Facility Phone u__.2 0_�Z� '� <br />(h.►nttrof [)c.ignutc <br />�� — llpdaK l'ereiticatc F;x <br />lhc;rotvr <br />rution Date <br />Designat <br />L' NT QXLera tolls) for this citjty <br />PRIMARY <br />f)elignated Operator's Name: �C/� <br />7 C , Rciution to iI - F' Facility ( <br />hrrk One) -- - <br />Bu.inr.,� Mame I lJ drff :renl Jrnm uh+n r1 <br />�r ISL +Y/ ,R�QL►�C'T p (Tperat <br />O Employee <br />Ucsigrtated operat(ir's Phone it:. <br />ID xScrviet Technician <br />Third -Party <br />Intermaimul Code Council Ce-mliration 4: <br />Expirmion Date: <br />ALTERNATE I (gpdoeaQ <br />rh ignatrei Operntvr's Namc: <br />Rcl:itiun to IJST Facilitl ( <br />�L <br />hack One) <br />Business I nmc 1 differenr/rom abuve): <br />()esiKnatrd ()peru(or's Phone b: <br />d ()H ncr 1�7 O perwor <br />O F,mpluyec <br />a Scr.icc Tcchnician <br />Third -Party <br />Inlanationa) Cudt Council t-enitiration d: <br />Expiration Date: <br />ALTERNATE 2 eopdama!) <br />D"ignabed Operator's Name: <br />Relation to UST Fweilit y ( <br />c•ck Char) <br />Husine?• Narnt (!f'JrfJ'rrt•nt from ubnvrl : <br />l�ardtor's Phone At.❑ <br />D ()weer ❑ t)peratnr <br />❑ Employee <br />Srniu; Technician <br />'Chird-Pvty <br />Intcrnatirrnul Code f'uuncil C'ertitii ,tion �: <br />Expiration Ute <br />I certify that, for the facility indicat at the top of this page, the individual(s) list -1411 <br />ove will <br />serve as .Designated UST C)wrator( The individuals) will conduct and documemonthly <br />taeility inspections and annual faeili employee training, in accordance with Caliis Code of <br />Regulations, title 23. section 2715(c (f), <br />-thermolre, I understand and a, <br />ulations, and local ordinances) <br />NAME OF TANK OWNER (Please Prjn <br />f IGNATURE OF TANK OWNER: <br />i <br />.ATE: S <br />i <br />compliance witb the requirements (stat, <br />icable to underground storage tanks. <br />,til~A'S PHOfvE �: a c � 6l�v� �rri� <br />OTE: F) SL`i81IlT rFitlS Co;NtaaLFTEDtRIVI TO THE LOCAL AGE.NCY (NOT THE ST, `rE K'.4TER <br />ESOURCESCONTROL BOARD) BYUARY 1, 205. THE LOCAL.�{;ENCX LIST tCAlLABI_.E <br />NOTIFY THE LOCAL AGENCj- OF f Y CHANGES TO THIS I VFOR-MATION WIT HI130 JDA YS <br />F THI` CHANGE. <br />i <br />r <br />s <br />