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�----Owner Statements AD)esignated Underground Storage nk (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />- T -Ream wr <br />PRiASARY <br />Desi te+d ate.—s r _ a - x I= m UST Facility eeb�x omj <br />ua;a>ess IJamc (Vm:Tr f above) -- _- _ _ _ — _ . r0 owma 0 Operator 0 Frnployee--� <br />© Smicc Tedmidm tr Third -Party <br />Desirsw 9PT!a a s Phoste Cl 1 'Q ,Z <br />4 _ <br />>ndarrudw at Code 6wal Crrti& d- _-__ C Z q �, _- u �r___��► 2 _� _ _ <br />ALTERNATE 1 A <br />L C� Cox t 's Name. ---- --- elation to UST Facility fC k. k Ow) l <br />mw� � ---- --- o oma« o Opwww ❑ FAwlq5w' <br />0 Servke Tedmidan O Third <br />O Service Todm_ician _O Tbini-Party <br />Dasisomed_ s Phyte 0: — <br />I cettafy t it, for the facility Wicated at the top ofthis page, the uti jvAual(s) lisle( above will <br />serve ars D� UST Operator(s). The individuai(s) will conduct and docunxmt =nthly <br />fiiciHty ins and annual facr7it) employee tr=hW,, in K cosdawe with California Code of <br />R,eguia Wns, title 23, section 2715(c) (f). <br />I~urthet-mote, t understand and stun in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Pr€st): <br />SIGNATURE OF TANK OWNER: <br />DATE: �cy� - ✓ - CJ OWNER'S PHONE N: <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 <br />AVAILABLE AT: www.watgtgAL411,;g.itovAiWcontacts/cuDa gMS ht 1. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION i) ys <br />OF THIS CHANGE. <br />DEC 2 1 %004 <br />ENVIR0N1,1f-`!f <br />PERMI ,,S!:..RV11G'ES <br />h ternaf W Code C wdl Ci7'iiftedw <br />Fax ration Dae: <br />AI:I'ERNATE 2-- <br />Lftimaided OpuaWs Name: <br />- Relation to US'r Facility (Check ow) <br />O Service Todm_ician _O Tbini-Party <br />Dasisomed_ s Phyte 0: — <br />I cettafy t it, for the facility Wicated at the top ofthis page, the uti jvAual(s) lisle( above will <br />serve ars D� UST Operator(s). The individuai(s) will conduct and docunxmt =nthly <br />fiiciHty ins and annual facr7it) employee tr=hW,, in K cosdawe with California Code of <br />R,eguia Wns, title 23, section 2715(c) (f). <br />I~urthet-mote, t understand and stun in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Pr€st): <br />SIGNATURE OF TANK OWNER: <br />DATE: �cy� - ✓ - CJ OWNER'S PHONE N: <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 <br />AVAILABLE AT: www.watgtgAL411,;g.itovAiWcontacts/cuDa gMS ht 1. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION i) ys <br />OF THIS CHANGE. <br />DEC 2 1 %004 <br />ENVIR0N1,1f-`!f <br />PERMI ,,S!:..RV11G'ES <br />