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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> ra ill AaTress R o A., ��.,,, _.• r � .... .- •. <br /> Reason for Submittin this Form(Check One <br /> Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Desianated UST Oaerator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R ArnaiZ Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 518-4836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATE 1(Option .:,,• ' '`' `' " e <br /> Designated Operator's Name: `a, ? u:-. Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Q ❑ Service Technician ❑ Third-Party <br /> #International Code Council Certification#: null l C_,0,js)7� Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: = Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration 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 2715(c) - (f). <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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: O r( OWNER'S PHONE#: 2.91 —L401 �"�9 2— <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 AVAILABLE <br /> AT: www.waterboards.ca.gov/ust/contacts/cupa ages html. <br /> 7)NfITZT �[rFi, -A I. A r_FNI-V nL- A WX1!'LT A%TO-VC'rte grTTTv TXT, T%-.m...�,.. ...���. . . <br /> November 2004 <br /> T00[A .LH)IHVI1 SKINCIX3 b92ZEL69T6 XVJ VC:8O Z90Z/6Z/80 <br />