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Owner Statements of Designed Underground Storage 't'Hnk (UST) Operator
<br />and C)nderstanding of and Compliance with UST Requirenients
<br />Fac;tity
<br />Va --- —
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<br />h'.,1ty Addrpar: h I'notlity IJJ i!;
<br />��v`i� �►'-r�,]Gtr,�.,f��.ty �,,L,�, acsxt�,eor8uhn,itting thisFc,rm- Chrck --- I
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<br />y,.ilily Ptxxie /!: �() - nn ,e
<br />Chmlgo nI 005-ignt�Scd Opermoi
<br />v �r.5 (- /�'� _ lJ}riata Lrniifioulu i?x ,irz,tum llortc
<br />sism"ed UST Unew�r.�ra<$) for this Facility
<br />PRIMA Rv
<br />1?os' ttteCd
<br />. � l+aratar's Noma ----- --- -- --
<br />Relutica, it) USt 4 ticiHty ([:hock, 0170
<br />t3u�iaesxNameWA e,rewfnma"e): Tj r
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<br />1 )l,.,l na1Cd C� ]CrAt{,r'N PIlnR@ ♦f
<br />jl I+,tvmaticmul Code C ouncil Gert >,ca �l1 ^ Q J— Servioo 'l uohnic;un I'Irird-Narly
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<br />A_LTEI2NAT$ 1 (i�pli�all -- •- —_ /�
<br />I)caignotod (}fwrntur'r Name:
<br />13u4own Name (/,feWor o from above):
<br />Dcyignalod OPe 1101''1, Phunu R:
<br />Ntmoticmal Code ununcil (:urtitication a.
<br />At,'r�UNATr 2 ,`Dnr1,m.h
<br />Relatiup to UST };no;lity (Check One.)
<br />CJ (AVnar ❑ Otx rotor r I'n Jd, ycc
<br />Rurviw'l'ochniaipn ,Third --forty
<br />P.xpiration 1.).l.:
<br />i
<br />lleyignuu,d nperatar'a NR ..ST-,F
<br />—Fac-----_..__......
<br />4K /i�r' ]tolutiart t:, IIility (Ch0VA Cann)
<br />i3usinuxx Name {If dVt-wwfroze, a r,
<br />_ n (hv,or i ; C)I,crelcr Ci l.n,t>Jnyr,.
<br />DExignatod Uporaun''x PhcNto
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<br />•, ,� - Servica'l'c,ctwicien Third. Party.
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<br />ititativa ll: �C) -...
<br />ixpiraticu,
<br />EGULATORY AGENCY MUST BE NOTIIEIID OF ANY CHANGES 1'U THIS
<br />N WITHIN 30 DAYS OF THE CHANGE,
<br />.94
<br />ioWmati mul Codo Council
<br />NOTE: THE LOCA
<br />INFORMA'IVI
<br />I cttrtify 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 molithly
<br />facility inspections and annual facility employee training, in accordance with California Cc,d 0 0f
<br />Regulations, title 23, section 2715(c) - (f).
<br />Furtherrnoi'e, I understand and am in compliance with the requitvinents (statutes,
<br />riegulotions, and local ordinances) applicable to underground storagt. tanks.
<br />NAME OF TANK OWNER
<br />OR OWNER'S ANENT (P'1ensu Print)i
<br />SIGNATURE OF TANK
<br />OWNER OR OWNER'S AGENT:
<br />DATE: 2 OWNS, 'S PHONE 0: � Cl�_ Cir J_1 —
<br />Septomher 2Uod
<br />Td WUt -S=80 600, LO •_tdU 8626LZS60?: 'ON XUJ •oo dwnd aaluotI: 1 od0
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