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-;-fwncr Statements o. esignated Underground Storage Ok (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />FLK!rlty <br />PRIMARY 6 to UST Facility (Check OW <br />wed a Nam= L a w. —$A-% dir 14 LA TRaim <br />I <br />Busiam Now OpnW E <br />jj] <br />0 SaviccTechmkiw W Thkd-PwV <br />Desi tod Opwows Phow 1 (0 - 1? z -! S -its <br />Wamdaral cAde camidl carnification <br />ALTERNATE I (00do*4 1; - UST Fadfity (CAwckQw <br />Dcs4pdad g2g��s Name: ^--T R�latiau <br />Busimn Name Tdipreq Pon above): 0 w <br />0 Sn-viwTwkiW= 0 Lhlrd-Paq <br />Dcs*xted qpT!!Lw's Phone #: <br />Wanddooml Code CouncH Cadficatkn 0: <br />fj-- -- Dote: <br />ALTERNATE 2 (�qg <br />Dna ?pwatar's Now: <br />Rcbdm to UST FuRity (Check Ow) <br />Busies Nina 13 O*vw E3 OMatw Em )rx <br />above).- <br />13 Sa-viwTedmkim 0 TW064" <br />maedi opo" 's Phone #: I <br />kdanadmd Code Council Cadfiaidw I Expiration Dow <br />I certify that, for the facility indicated at the top ofthis Me, the individuaks) fisted above will <br />serve as Des*naW UST Operator(s). The individual(s) will conduct and documemt 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 auderstand and an is compliance with the requirements (statutes, <br />regulations, and kKW ordinances) applicable to underground storage tasks. <br />NAME OF TANK OWNER (Mew hist): <br />SIGNATURE OF TANK OWNER: <br />DATE: A -,(5- - V � OWNER'S PHONE S: --2-0 ':7(- �3/- 36-^L <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARif 1, 2N& THE LOCAL AGENCY LIST IS <br />AVAILABLE AT: www.waterboards,ca,g&y/qg&0t wo am - <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION36 DAYS <br />OF THE CHANGE. "n� , IN, I i <br />DEC 2 1 2004 <br />ow ENV1R0NNit.-i,1i �U-%Jh <br />P F.,11 <br />ER <br />