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May 2914 07:11 a kcp 2098871904 p.1 . <br /> RECEIVED ' <br /> MAY 2 9 2014 <br /> Owner Statements of Designated Underground Storage Tank(UST)Operator <br /> and Understanding of and Compliance with UST RequiremelVIRONMENTAL <br /> HEALTH DE TMENT <br /> j Facility Dame: %/( Facility ID it: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> L-(e1 X i>::}+�C. �7EI-mac.; l'n S-n cvi"s c.a VICChange of Designated Operator <br /> Facility Phone#: cry of �) -1 S 1 D update Certificate E. iration Dare <br /> Designated UST Operators)for this Facilites <br /> PRIMARY <br /> Designated Operator's Name: - i Relation to UST Facility(Check One) <br /> Business Name{If d�erent from abo _l e4 r y p Owner ❑ Op:rator ❑ Employee <br /> Designated Operator's Phone#: b c? � 5 Ja`Service Technician Q-Third-Party <br /> International Code Council Certification#: S Expiration Date: <br /> ALTERNATE 1 O !lana <br /> Designated Operawe s Name: Relation to UST Facility(Check One) <br /> Business Name(ffdlferenr from above): ❑ O mer ❑ Operator 11 Employee <br /> Designated Operator's Phone#: O Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name, R=STCheck One) <br /> Business Name(If different from above)_ O D Employee <br /> Designated Operator's Phone#: QD Third-Party <br /> International Code Council Certification#: 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): Vs"-L-4C-'C <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 5 $ -La I c{ 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 LOCAL AGENCY LIST IS AVAILABLE <br /> AT:t. �,.c' iLrilQi«?'dS.CH.r.O';`,t?�ift:;�ITiBCiF t 11t1 3.Illlili. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />