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7 7 7 11 H '66 *21V IWIJ P;AI ;D;� <br /> Owner Statements of Designated Underground Sto ge Tank (UST) Operator <br /> and Understanding of and Compliance with ST Requirements <br /> Facility Narne: `611 c ility ID#: <br /> U )_11 lt'_ <br /> Facility Addre%�;: ?f a-son for Submitting this Form(Check One) <br /> 17 -tChange of Designated Operator <br /> S 5. <br /> -Rucility Phone Update Certificate Expiration Date <br /> Designated UST Operator(s) for thi Facility <br /> PRIMARY <br /> Designated Openaor-s Name: Karen R Arnaiz 'lation to UST Facility(Check One) <br /> Business Name Q('&jjLr,,n1ftmn ahove): Owner 0 Operator 0 Employee <br /> -Designated Operator's Phone fi:(209)5184836 I Service Technician X Third-Party <br /> International Code Council ceiiii-nationff:8032295-UC -pirdion Date:06/11/2013 <br /> ALTERNATE I (Optional) <br /> Designatc%l Operator's Name: elation to UST Facility(Check One) <br /> Business Name(1fdijjLrentTrow above): Owner 0 Operator 0 Employee <br /> Designated Operator's Phone 11: Service Technician 0 Third-Party <br /> I/International Code Council Certifieation fl: piration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: elation to us,r Facility(C-heck One) <br /> Business Niunc Qf(Ifficren1fi-onz above): Owner 0 Operator 0 Employee <br /> Designated Operator's Phone-9: Service Technician 0 Third-Party <br /> International Code Council Certification fl: xpiration Date: <br /> I certify that, for the facility indicated at the top of this page,t individual(s) listed above will <br /> serve as Desi(:inated UST Operator(s). The individual(s) will c duct and document monthly <br /> facility inspections and annual facility employee training,in ac rdance with California Code of <br /> Regulations., titic 2.3, section 2715(c) - (1). <br /> Furthermore, I understand and am in compliance with the equirements (statutes, <br /> regulations, and local ordinances) applicable to undergrou storage tanks. <br /> NAME OF TANK OWNER(Please Print): '-AA k,�_ N—\ SN\A r.W)l, <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#-. „ q 2- <br /> NOTE: I)suBmiT THIS COMPLETED FORM TO THE LOCAL A NCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD) BY JANUARY 1,2005.THE LO L AGENCY LIST IS AVAILABLE <br /> AT: <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS I FORMATION WITHIN 30 DAYS <br /> OF THE CHANCE. <br /> November 2004 ■ <br /> ■ <br /> ■ <br /> ■ <br /> T -d a990_S*1S_G0a je2ueW PqqoE esa :60 LO as Jew <br />