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-Jan 25 10 01:17p Reliable PetroleunnA 209-845-8953 p.3 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Facility Address:o'16-7-75 -S . Facility ID #: l'%'EE'rSa1n -l!�in'r a I�Q Reason for Submitting this Form (Check One) rJ 3-7 ❑ Change of Designated Operator Facility Ph ' one #: --Ud — S— % Update: Certificate Expiration Date Designated UST Operator(s) for this Facilitv PRIMARY Designated Operator's Name. Business Name (O dig trent jrom ubov) t �� Designated Operator's Phone #: ------------- International Code Council Certification .'xLFERNATE I 6OWionff9 Designated Operator's Name: Susincss Name (y- rerent from above): Designated Operator's Phone #: International Code Council Certification k: ALTERNATE 2 (Optional) Designated Operator's Name: Business Name (If dierertt from above).- Designated bove):Designated Operator's Phone #: International Code Council Certification #: Relation to UST Facility (Check One) CP 7 Owner ❑Operator O Employee Service Technician ❑ Third -Party J Q^`(..�1✓ Expiration Date: � � � t' Relation to UST Facility (Check Une) O Owner ❑ Operator O Emplovec ❑ Servicc Technician ❑ Third -Party Expiration Date: Relation to UST Facility (Check One) O Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tames. NAME OF TANK OWNER (Please Print): }S 2� SIGNATURE OF TANK OtiVNER;n DATE: I, 13j ( G _ OWNER'S PHONE #: l NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. TfIE LOCAL AGENCY LIST IS AVAILABLE AT: ti�yu:u_Etr_Lirtarctc-� a.,r�_i s_.:c��iit;�cis i:tt,a a r s.lt[rni. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.