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08/31/2009 08: 58 2098251004 THE UPS STORE3508 ' PAGE 01/02 <br /> AIN <br /> AUG 31 2009 <br /> Owner Statements of Designated.Underground Storage Tank (M),JQ rator <br /> and Understanding of and Compliance with LIST Rcquirci2ss p� ;V;,Je <br /> Facility ID#: <br /> Facility Name: <br /> Facili Address: Rtason for Submitting this Form(CherJk Urre) <br /> ty 14 lQ mea n Stre_ <br /> a5 Change of Desigmated Operator <br /> X Update Certificate Expiration Cyte <br /> Facility Phone it <br /> Designated UST ORerato s for tb,is Facili <br /> PRIMARY <br /> Designated Operator's Namc:Karen R (�,rnaiz Relation to UST Facility(Check Oar) <br /> Business Namc(Ifdigerentfrom above)' Ci Owner 11 Operator [IEmplovcc: <br /> c Service Technician X Third-Party <br /> Designated Operator's Phone#: (209) 518-4836 <br /> international Codc Council Certification 4:8032295-UC <br /> Expiration Date 06/20120111 <br /> ALTERNATE 1. D tion!) - <br /> Designated Operator's Name: F.elation to UST Facility(Check One) <br /> Business Name(ifdifferent from above)' C7 Owner t Operator 11 rmploycc <br /> Designated Operator's Phone tf: L] Service Technician E03 Third-Fatly <br /> #intcroational Code Council Certification 4L, Iixpiration Datc_ <br /> : - <br /> ALTERNATE 2 (OpSonal) <br /> Designated Operator's Name: Relation to UST Facility'(Check Otc) <br /> Business Name(l�hhorle <br /> nt front above)- 13 Owner Cl Operator 0 Employee <br /> Designated Operat;: ra Service Tcehnician 0 Third-Party <br /> International Codc Council Certification#: <br /> lSxpiration Date: <br /> I certify that, for the facility indicated at the top of this page, <br /> the individual(S) listed above will <br /> serve as designated.UST Operator(s). The individual(s)will conduct and document montbly <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 tunks. <br /> NAME OF TANK OWNER(Please Print); r j YV' n 2 A <br /> SIGNATURE OF TANK OWNER: <br /> . 144, fig Lj'a <br /> DATE: 02� OWNEIR°S PHONE#: 9 09 —LA-01 =5:;7 9 2-- <br /> NOTE ]) <br /> - <br /> NOTE1)SUBMiT TENS COMIgZnD FORM TO THE LOCAL AGENCX(MT THE STATE WATF,R <br /> RESOURCES CONTROit.SOARb)BY JANUARY I,2005.THE LORAL AGENCY LIST IS,A,YAILAhLE <br /> AT: \v",Nv_i aterboards.ca__;o�,ust;contacts/cupa ;tsws.htmf. <br /> 2)NOTIFY THE LOCAL AGENCY Off'ANYCff,�NUE,5 <br /> v-rhT O�' '"INATIOnT <br /> aLECdIANGV, JV WMIN16AAVS <br /> November 2004 <br />