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9tiN ',N Wd�' 'P, MZ '6Z 1V 9W11 pani a�a� <br /> Owner Statements of Designated Underground St age Tank (UST) Operator <br /> and Understandillg of and Compliance with ST Requirements <br /> Facility Name: "r1k (. k,�i acility ID : <br /> Facility Address: /S51LC_''. r ,j� _ Cason for Submitting this Form(Check One) <br /> Ci LC� _.{�j. �. Change of Designated Operator <br /> Faedity Phone If Update Certificate Expiration Date <br /> Desigrnated UST Operator(s) for thi Facility <br /> PRIMARY <br /> Designated Operator's Name: Daren R ArnaiZ , elation to UST Facility(Check One) <br /> Business Name Q1 di))irr(!n[/i-om shore): — 1 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone d:(209)518-4836 Service Technician X Third-Party <br /> Intcmational Code Council Certification r:8032295-UC xpiration Date:06/11/2013 <br /> ALTERNATE 1 (O tiana1) _ <br /> Designated Operator's Name: _A elation to UST Facility(Check One) <br /> Business Name(1%diJ•/ereni ftonr above): Owner ❑ Operator ❑ Employer <br /> Designated Operator's Phone H: Service Technician ❑ Third-Parry <br /> #International Code Council Cenilkxaiott !;: spiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator',Name: elation to UST Facility(Check One) <br /> Business Namc((jdi/);Feld ain above) --- Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 4: ^�^ Service Technician ❑ lbird-l'arty <br /> Intemational Code Council Certification :- - __--- pirationDate: <br /> I certify that, for the iacility indicated at the top of this page,th individual(s) listed above will <br /> serve as Desionated US`1' 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, title 23, section 2715(c) - (f). <br /> Furthermore, 1 understand and am in compliance with the quirements (statutes, <br /> regulations, and local ordinances) applicable to undergrou storage tanks. <br /> NAME OF TANK OWNER (Please Print): ' — 1� •r r <br /> 7 <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE t#: 209 —'U01 - <br /> NOTE: 1)SUBMIT TIIIS COMPLETED FORM TO THE LOCAL A NCV (NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD) BY JANUARY 1,2005.THE LO L AGENCY LIST IS AVAILABLE <br /> AT: ►�►►►v.��,ttcrhuards.ca,_�;�'usl turutcls cul�tt <t,vs.htill l. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS I ORMATION WITHIN 30 DAYS <br /> OF THF,CHANC E. <br /> November 2004 <br /> E 'd 2990-SbS-60z ge2ueW RggOE eSa :G0 LO as JeW <br />