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Owner Statements c"'7esignated Underground Storage "­nk (UST) Operator <br /> and Understa..ding of and Compliance with USI ..equirements <br /> Foality Name: � � �� \ n Facility�t!: <br /> Facility Address: _.l.J Cj) U!/�- Reason&x Submittingthis Form(Check <br /> One) <br /> -- Chace of D,ssi aced_operwwr❑ <br /> Update Certificate Expiration Date <br /> I Faecic <br /> -�---- -v�.-�- -9 S. 7.. <br /> Designated UST Operator(s) for this FacilitY <br /> PRIMARY <br /> �Desip�nated Operator's Name: L.o K.t r 1�E 5_N O 1.1 Iq------r Relation to UST Facilit�(Check One) J <br /> Business Name(Ijdi$erem from above): 1 .0 Owner ❑ Operator ❑ Ernployee <br /> ❑ Service Technician MThird-Party - -- <br /> Designated Operator's Phone#: ctl t• - $2 to- 16-1 la <br /> I international Code Council Certification#: SZ2 O3 53 1.1 Ci_— Expiration Date: 1- 14. O-. <br /> ALTERNATE l fQ iional <br /> Deserted Operator's Name _ _ _._.._ Relation to UST Facility(Check One) <br /> Business Narrtc(lf different front above): f ❑ Owner ❑ Operator ❑ Employee <br /> ❑ Service Technician ❑ Third-Party _— <br /> ' Designated Operator's Phone i!: <br /> Internloational Code Council Certification - Expiration Date_— <br /> -----aC - - -- <br /> ALTERNATE 2 (OptinRa/) -- --- -------. <br /> llesignated s Name:— ---- - —- ---------LRelation to UST Facility(Check One1 <br /> Business Name(If different from above): I ❑ Owner ❑ Operator ❑. Employee <br /> ❑ Service Technician ❑ Third-Party- - --_ <br /> Designated Operator's Phone il: 1 <br /> I International Code Council Certification!i: Ex iration 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 271-5(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 P <br /> SIGNATURE OF�TANK OWNER: <br /> DATE: ` —T D LA, OWNER'S PHONE#{: J 7_�_ 3 4 <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 <br /> AVAILABLE AT: www.waterboards.ca.gov/tkgt/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATi 0 DAYS <br /> OF THE CHANCE. <br /> DEC 3 0 2004 <br /> FAV(RONMENT HEALTHPERM�T/SERVICES <br />