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RECEIVED <br />MAY 3 0 2014 <br />Owner Statements of Designated Underground Storage TanWA&erator <br />and Understanding of and Compliance with UST RequilmIl�nf Rule SLrl-1 <br />Facility Name: \( t L --L tl G- <br />Facility ID #: <br />Facility Address: <br />Reason for Submitting this Form (Check One) <br />E c-7 3.T��c}e t -� <br />M` hangeofDesignatedOperator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: , cj j / <br />Designated UST Onerator(s) for this Facilitv <br />Designated Operator's Name: <br />Business Name (If dierent from abov <br />Designated Operator's Phone #: a oc? <br />International Code Council Certification #: <br />ALTERNATE 1 O bona[ <br />Relation to UST Facility (Check One) <br />Z❑ Owner ❑ Operator ❑ Employee <br />,k' Service Technician Q - Third -Party <br />Expiration Date: %.—/ <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierent from above). <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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(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): VO'y--" 6- f— wPzST /--% 4—t ^--,--4 <br />SIGNATURE OF TANK OWNER: <br />DATE: _ S� I I - o 1 �{ OWNER'S PHONE #: <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANSARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.watcrboards ca Dov/tist/contacts/cupa a,, 5 httnl. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />