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D <br /> Owner Statements of Designated Underground Storage Tan ,��V=r <br /> and Understanding of and Compliance with UST Regy)Mge�t , <br /> 00 <br /> Facility Name:,T L Facili ID#: ENp IRGNMENT HEALTH <br /> Facility Address: Reason for Submitting this & (check one) <br /> ?/J /U Jo /*,Ua Change of Designated Operator <br /> tf049 1,t Update Certificate Expiration Date <br /> Facility Phone # 7.f' <br /> Designated UST Operator(s) for this Facility <br /> Prima <br /> Designated O erator's name: Dan Mcllrath Relation to UST Facility(check one) <br /> Business Name: Valle Underground Tank Monitoring ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone#: 209 649-8956 ❑ Service Technician U Third-party <br /> International Code Council Certification #: 5246558-UC Expiration Date. _ <br /> 1 L-2001 <br /> Alternate 1 <br /> Designated Operator's name: Relation to UST Facility(check one) <br /> Business Name: ❑owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification #: Expiration Date: <br /> Alternate 2 <br /> Designated Operator's name: Relation to UST Facility(check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification JExpiration Date.- <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br /> THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br /> Designatd UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, <br /> title 23, section 2715 (C) - (F). <br /> Furthermore, 1 understand and am in compliance with the requirements(statutes, regulations, <br /> and local ordinances) applicable to underground storage tanks. <br /> Name of Tank Owner <br /> or Owner's Agent(Please Print): �' ����� V r-j <br /> Signature of Tank <br /> Owner or Owner's Agent: <br /> Date:�b -��-g , -7 Owner's Phone#: J�/p - o Fay <br />