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Owner Statements of signated Underground Storage T : (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Fata <br /> lit Reason for Submitting this ForMf(Zhwk _ <br /> One <br /> 0 Change of Designated Operator 0 <br /> Certificate Expiration Date <br /> FacflityPhone#: (19- 173i- '-74 I <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> I Dcdvuftd 00raWs Name: (.0 IL 1 rr E S 14()LA IQ, Relation to UST Facility(Check One <br /> Business Name(If&Oerenlfirow above): -Owner 13 Operator 0 Employee <br /> 0 Service Technician If Third-Party <br /> Designated Operator's Phone#: 114 - 2 Z In- 16-1 (a I$ <br /> International Code Council Certification#: 5z,z.a LA C,, I Expiration Date: 16 <br /> ALTERNATE I (Opfional <br /> Designated Operator's Name: Relation to UST Facili CCheck One <br /> Business- Name(If4ffirqdfraw above): 0 Operator 13_Employee <br /> 0 Service Technician 0 Third-Party <br /> Designated Operator's Phone#: <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opdonal) <br /> Designated Operator's Name: Relation to UST Facility(Check One <br /> Ffrom above): <br /> p�mes�Aaq,!P.(if different 0 Owner 0 Operator 13 Employee <br /> 0 Service Technician 0 Third-Party <br /> Designated ierator's Phone#: <br /> International ,ode Council Certification#: Expiration Date. <br /> I certify that, for the facility indicated at the top ofthis page, the individual(s) fisted 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) - (0. <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): , 'I1iv-10-1 " OR <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: 1-5 C� c-131-36-74 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STAftf <br /> �7�WAT <br /> Wt"- <br /> RESOURCES CONTROL BOARD) BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS ,, ' : <br /> AVAILABLE AT: www.waterboards.ca.gL)v/ust/contacts/cupa agys.html. iJEC 2 1 2004 <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION HIN 38 DAYS <br /> OF THE CHANGE. MiRONMEN F HEALTH <br /> PERM/T/SERVICES <br />