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Aug 30 10 03:10p Reliable PetroleumA 209-845-8953 p.2 <br /> I <br /> i <br /> Owner LStatements of Designated Underground Storage Tank (UST) Operator <br /> d Understanding of and Compliance with UST Requirements <br /> Facility Name: <br /> A- 1 <br /> r• `Z.e S Facility IDF:IityAddress: Reason for Submitting this Form(Check One) <br /> -755 l� Change of Designated Operator <br /> � (;.pdate Certificate Expiration Date <br /> Designate UST O erato s for this Facili <br /> PRIMARY <br /> Designated Opera is Name: <br /> - Relatii n to UST Facility(Check One) <br /> Business Name(! EEm above): (�, ��� <br /> ��2v,�p ❑ Owner ❑ Operator EJ Employee <br /> Designated Op : 2pet �O <br /> `-1—R33(o �' Service Technician D Third-Parry <br /> International Code ouncil Certification#: SaS�.S d `LUG <br /> Expiration Date: (2 3 r <br /> ALTERNATE i tfvnal <br /> Designated Operat 's Name: <br /> Relation to UST Facility(Check One) <br /> Business Name(!f fferenrfrom above): <br /> Designated O ❑ Owl ter ❑ Operator ❑ Employee <br /> gra peva 's Phone#: <br /> International Code ouncil Certificati ❑ Service Technician ❑ Third-Party <br /> ALTERNATE 2 Expiration Date: <br /> raara!) <br /> Designated Operato s Name: I <br /> Business Name(If Brent from above): Relation) to UST Facility(Check one) <br /> Designated Operator s Phone#: ❑ Om L r ❑ Operator ❑ Employee <br /> International Code <br /> uracil Certification# El SermeTechnician ❑ Third-Party <br /> Expiration Date: <br /> Ffy that, fo the facility indicated at the top of this page, the individuals) listed above will <br /> as Design d UST Operator(s). The individuals) will conduct and document month]y <br /> y inspecti s and annual facility employee training, in accordance with California Code of <br /> Regulations, tit) 23, section 2715(c) <br /> I <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations,anc local ordinances) applicable to underground storage tanks. <br /> k NAME OF TANK{ WNER(Please Print): •S;t"//'" ,�� <br /> �G SIGNATURE OF ANK OWNER: = � <br /> DATE: OWNER'S PHONE <br /> NOTE: 1) SUBMIT rHIS COMPLETED FORM TO THE LOCAL AGENCY <br /> OT THE STATE WATER <br /> RESOURCES CON ROL BOARD)BY JANUARY 1,2005.THE LOCAL AG NCY LIST S AVAILABLE <br /> AT: '.yFvtV.\(att['h01i'r .Cu.�Ob/l3SL'_OntactL , <br /> --- _gg s.html. <br /> 2)NOTIFY THE LC CAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br />