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ii 4 F' <br /> 1 p + <br /> Owner Statements, of Designated Underground Storage Tank, (UST) 0kkioz f�11, <br /> and Understanding of and Compliance With UST Requirements;, +, , t <br /> Facility Name: 715 K5 ,t. i-e. �uf � Faciijry IIs#: <br /> Facility Address: 11CLI n J Rcason for Submitting this Forme(Cheek One) <br /> 1 i W 5 � C�t 5�' Gt C��CG� _M^ x Change of Des gated Operator <br /> Facility Phan 9: � Q updam Cuteticate E�Eratmn <br /> Designated UST Operatort4j for this Facility <br /> PRMARY <br /> Des Zperator's Name: r�•y�� �nC� - RclF+tion to UST Facility(Check Ogre) <br /> 13usLness Naav(if dijerent from above):U.�r e � ` aA EC] owner ❑ Operator ❑ Employee <br /> Designatcd Operator's Phonc#; `ate •4 Service TecbrAcian ❑ Third-Pity <br /> ltttemational Code Cnwieii Certification#: ^� 6,,pirat n Date: "1• l0• Z <br /> ALTFRPiA'T'E 1 taoma! <br /> Des,igrmred Operator's Name: Rclaaion to UST Facility(Duck One) <br /> Business Name(If different from above): Q ow= ❑ Operator ❑ Ewpioyoe <br /> Dcsigpated Operator's Phoac#: V d serviea`rcc nician Th rd-Party <br /> ]n[eruational Codc Council Certification#: K _ � Expiration Date. <br /> ALTI',RNATE 2 (Optional) <br /> Dca gnstad Operator's Name: lteWon to UST Facility((.heck One) <br /> Business Name(Ifdiffereid from above): 2 pvrner ❑ Operator D Er►'LlLlnyee <br /> E Desipatted Operator's Phone#: ❑ Seraicc 1'echn.ician O Tbird-Party <br /> International Code Council CcrtificaiioU#: E�cpuatiorx.Date: <br /> FicerL;y that,for the facility indicated at the top of this page,the individual(s) listed above Will <br /> serve as DesigtWed UST Operator(s). The individual(s) will conduct aad document monthly <br /> facility inspections and annu=al facility emp ogee training, in accordance with California Code 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).T.,IAS G3 g /C MA DD A- <br /> SIGNATURE OF TANK OWNER: 99 <br /> DATE- — 1 OWNER'S PHONE#: 2-0 9— 02- <br /> NOTE: 1)SUBMIT THLS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 11 2005,THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: rtiti�V'.V.Nits'�CSU1f�S.Ccl.t��lv/LLStii'clElt�t:;t�%i.�tUil �i�WS,�,,ht27lf. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WIT". 30 I�t1Y� <br /> OF THE CHAINGF,. <br /> November 2004 ' <br />