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AUD-03-2010 07:08 Se&ce Station Systems 408 938 8888 P.04 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name- Facility ID#: 2-7C7 <br /> Facility Address: .1 1 zG) �'I C 1�{Pl7 t,(,� Reason for Submitting this Fonn(Check Otte) <br /> T C' ( Change of Designated Operator <br /> Facility Phone#: — ❑ Update Certificate Expiration Date <br /> ➢eshmated UST Ooerator(sl for this Facility <br /> PRIMPRIMARY <br /> R Operator's Name: 1 a Relation to UST Facility(Check One) <br /> as <br /> Business Name(Ifdij/erent from above): I Qh SIC ❑ Owner ❑ Operator_/❑ Employee <br /> Designated Operator's Phone#: — —,2, 5 Z Service Technician Cr 'ntird-Party <br /> International Code Council Certification#: Expiration Dere: 7��. la <br /> ALTERNATE O ion <br /> Designated Operaror's Namc: 1Qr)e F1or Relation to UST Facility(Check One) <br /> Business Nam(If d(pkrentfrom above) I -Un SLIM Owner ❑ Operator D Employee <br /> Designated Opttator's Phone#: —911-144 5 service Technician PjThird-Party <br /> International Code Council Ccnifiutim#: -Pa49c0l— C Expiration Date: I '7 11 <br /> ALTERNATE 2 (OptionuU <br /> Designated operstor'a Name: Q rt fr1 Relation to UST Docility(Check One) <br /> Business Name(If dii ferenl from above)' n �^r1�1 ,' ❑ Owner LlOperator ❑ Employee <br /> Designated Operator's Phone#: —9-7 I'} 5 Le Service Tcehnician Third-Parry <br /> International Code Council Certification 4: ,j2,t} (O 9 - UC Expiration Date: (0/Z_45/ 11 <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 Code of <br /> Regulations,title 23, section 2715(q) -(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances) applicable tonderground storage tanks. <br /> NAME OF TANK OWNER(Please 7znmt <br /> SIGNATURE OF TANK//O,/W�NER: <br /> DATE: <br /> -7/�� //(/ OWNER'S PHONE N:' Cl2-S) ' '" ,^70/ <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST 1S AVAILABLE <br /> AT:w vw waterboards ca aovlusd(on[ac[stcut a ally tml. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 70 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> TOTAL P.04 <br />