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' Dec 28 04 12: 00p Aur Sibley - Sr. HSE Co 707- "i2-8947 p. 6 DEC 3 0 2004 EfJVI Ci i.'Ef� f HEALTH Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of Compliance with UST Requirements Facility Name: /3!i/43 Facility 1D#: t f 3 Facility Address: 6� Reason for Submitting this Form(Check One) ).b,,) �( t 11 X Change of Designated Operator Facility Phone#: 0 Update Certificate Expiration Date Desi Hated UST Oaerator(s) for this Facility PRIMARY Designated Operator's Name: SHE AL2 y S 04 v L Relation to UST Facility(Check One) Business Nam Qfdifferenrfromabove): De LTA Svviyzc )rSeurQC coNsut ,p owner ❑ Operator ❑ Employee Designated Operator's Phone#: 8v S- $6 - S S�� ❑' Service Technician X Third-Party International Code Council Certification#:U,urtvAIL p 5Le P 55/u Re DR Expiration Date: ,Vo r J 1 &/ c/1646 IQ rr}c!i E ALTERNATE Designated Operator's Name: Ly4/t_r2 'k1t61&)5 Relation to UST Facility(Check One) Business Name(ffdifferentfrom above):OeL.Tu✓irtau evrnL C0,01)c74_ ❑ owner ❑ Operator ❑ Employee Designated Operator's Phone#:Flo -7 oa.- b 8-7 q ❑ Service Technician X Third-Party International Code Council Certification#:S 3 IR 61_ v L Expiration Date: D ALTERNATE 2 O Designated Operator's Name: ytl Ke V4,,)42K L n Relation to UST Facility(Check One) Business Name(ffdifferenrfromabove):p T:Irvt 4u�i urnC ut r N ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: 30_ o S- 7 3 7 ❑ Service Technician X Third-Party International Code Council Certification#: J y I _ U LExpiration Date: 6 4/ 2oo 4 I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) -(f). Furthermore,I understand and am in compliance with the requirements (statutes, regulations, and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER(Pkaw Print): Mt S/6 SIGNATURE OF TANK OWNER: l(tj DATE: 4 OWNER'S PRONE NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: �v%iuw.Nvatcrboards.ca.Qov/ust/contacts/cuua a-y .littnl_ 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. l.Tn..nml.n.�nn�