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.. . _ 4rt,4� r, t r, I., & „&� PAGE 01 <br />DEC 2 9 2004 <br />EWP,ONIJIEW hb�CW <br />ICES <br />Ow ""Cr.Statemcnts Of Designated Undergmund Stcxu y ') Operator <br />and Understanding of and Compliance with UST Requirements <br />facility Nsttre 5' !Q� .L, (', , Facftity )p <br />C1 4 <br />�/ _ f�tAr j f �q t G4, Rawn rrr submitting rnm, ia rutt:'Mc4 04o <br />i 7�$�'i,ife-, AVC,. R r7 3� L7 C1tOn=e olDt+tisnstect [�xt,tor <br />P.citily Phone M. L:�1E 'jam C C dart <br />-d....r _ t crtirtcots Cx. iration Dot¢ <br />i rat r this 1' <br />ft <br />mMARY _�, ,.� <br />DWsnaw) pyearor s , w9c, j A w 1tt4 mion t0 US's ractlil <br />I�Str.�..ri.aY Y (neck d,eJ <br />sus>lness Nnfx Ufdes"rtrli's"r 6.7 nM.L JI-S,n 2l n7• b Own:r o Optrew 4 6mplcyee <br />I7+s Snatod (11+anttOr t Ptro*. �, lti J L) 11 > > Sarvioa 'T.�t,niCip p lhird.Panr <br />lntsmstionni CWc CyAncil Cirri. l000n s: 5 a y a c Eaplrstlon pstc' <br />[ktdgnoW Operawr's N et7mLALe�A <br />awinnss Nam Qfd*MRt jFoJir 044-t.l <br />frnemational Cl** Coutwil Cord fIC4;ion M. <br />A,LTEst%ATL 3 IpLno- <br />Dcstptased OW%tcr,'s Nafft 3,..; � <br />I %oz.1m Nttwtt 40"P, A w n e • a e .. (r, s • r t•.1 r�r�,.1 <br />t7ea;e„au4 Operotar's Phones 1i� L) T �, � <br />Ilx M160Jtsi Cadc Caulwil Ccrtiflcat�en N; <br />Aalatlon to UST Fadliry ((71WA Onr) I <br />C Owner C7 foperwr ❑ Ernptoy31 I+ <br />V scrir;u'reoniwan 0 Th-n-d--tar—ty�-�I <br />lexplretica Aata: , j a . I or -U f <br />Raluiap to :;ST raci. to (C.Nect Owe) <br />G Awuw C Oprgratar ❑ Emrloyrc <br />�/• 9arvtcr 1'aetinisisrt � T�+rd•Pany <br />Expiration 4ste s t - t) - ab <br />[I - <br />certify that. for the facility indiaxt*d at the top of this page, ft individua(s) listed above will l <br />serve as Desipated LIST Operawr(9). The iidividual(s) will oviduct and document monthly <br />fkeflity inq*ctioris mid arcual facility employrc train.132, in &=Tdsllce with Calif .4 Code of <br />Regulations, title 23_ section 271!(c) - ;f). <br />rvrthennore, I undta ntand and am in complionce pith the rsquirvotertta (statnttes, <br />regullttion% and ioesti *Minams) applicable to undergromd storage tanks. <br />NAME OF TANK OWNER (Phrase print); UkfPOUI _ JaJJ (�.Q1. <br />SICNATURE OF TANK OWNER: (Al tl?t J L2!=R&-'�- , <br />DATE. �1 - [ OWN ER'S PHONE <br />NO'i'tr: t) SUBA41T THIS COMPLETtp FORM TQ THE LOCAL AGLNCY gNOT THE STA FF, WATER <br />RL50t,RC%Ii CONTROL BOARD) BY JAN LARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILA8Lit <br />AT: �'r,X���Q�.�t�-'�if�45i��YS.�tC11• <br />2) Norwv THt 1„OCAL, ACENCV OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />or THE CHAtiGt. <br />vovarx�e* 2(►tla <br />J <br />TO 3Jtid Z a3JI1 Z8E ZEZ8 bE : E i VOOZ /6Z /Z T <br />