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ALO-03-2010 07:08 Se~ ice Station Systerns 408 938 8888 P.03 <br /> Owner Statements of Designated Underground Storage Tattle (UST) Operator <br /> and. Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility 1D# 747c7, <br /> Faciliry Address: 1 f J)��i Reason for Submitting this Form(Check One) <br /> Designated Operator <br /> Facility Phone N; <br /> 7 r O U au Certificatn Expiration Date <br /> Designated UST erator s for this Facili <br /> PRIMARY <br /> Designated Operator's Name: 1 Relation to UST Facility(Check One) <br /> pusiness Name(!f d fferenr from above): ( Uri S 1 C ❑ Owne' ❑ Operator ❑ Employ- <br /> Designated Operstor's Phone#: �� 5 Pf Service Technician [Y� ird-Parry <br /> International Code Council Certification#: �It/W Expiration Date: 7 7 <br /> ALTERNATE I O 11oga1 <br /> Designated Operator's Name: Jane r Relation to UST Facility(Check One) <br /> Business Name Qfdifferenr from above): 1 V11 ❑ Owner O Operator a Employee <br /> Designated Operator's Phone�: -111— l�Scrvice Technician �Third•Parry <br /> International Code Council Certification#: -Pa4ic01 C Expiration Date: I '7 i <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: 0 rt �n Relation to UST Facility(Check One) <br /> Susiness Name(Ifdiffer--from above)' i ''tt � ❑ Owner p Operator—/0 Employee <br /> Designated Operatoi s Phone#: — — 4'T V Servicc Technician 2 Third-Party <br /> international Code Council Certification Expiration Date; b12-51 1 <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 Cade 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(Please Print): <br /> SIGNATURE OF TANK OWNER: 11 <br /> DATE: OWNER'S PHONE <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAI.AGENCY LIST IS AVAILABLE <br /> AT:vr�vw.wstt't:rbyartls c;t eo / / � u�} Hs:Ys.h tttl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />