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May 05 10 02:07p Reliable PetroleumA 209-845-8953 p.2 Chvner Statements Of besignated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Nance: FacilityAddres:s: Facility ID 4: C, +rac tL- Reason%rSubmitting this Form(Cilt.,cp 0,1&) 7 0 Chan ge Of Designated Operator A.Update certificate Expiration Date Designated UST ODerator(s} for this F$cilitti PRIMARY DcsiLpiatcd Operator's Name: r N1 Rclation to U ST Faci I itv(Check One) Business\,.*am front bove}: Designated Operator's Phone 4: e Owner 0 Operator 0 Employee 0 International re.,4.,Council C-rtirlcat )n M: 5'1,5,2Service Technician 0 Third-Party _qL4 ALTERNATE I Expiration Mae: orrud Designated Operator's Name: 'ou '.�- Che R4�lation to tIST racillt:y(Cjjccp Business Nume i I One) iffdiLrereniftom above): 'One Designated Operator's Phone 0 Owner 0 Operator 0 Employee international Code Council Certification#: 0 Service Technician 0 Third-parry ALTERNATE 2F�piration Date: (0prjoij.1fl) Designated Operator's Name: ° Relation to UST Facility(Cizeek.one) 0 Designated Operators Phone 4: 13 Owner C3 Operator 0 Employee International Code Council Certification 13 Service Technician 0 Third-Part, Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will certify that, or f he facility I Employee 0 Service Technician 0 EEjC.X:p:i�rat�ionDtCc Fserve as Designated UST Operator(s). The individual(s)will Conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of t Regulations,title 23, section 2715(c) Furthermore, I understand and am in compliance with the requirements(sta t Mbil,e to underground storage tanks. regulations, and local ordinances) appli tu es t NAME OF TANK OWNER(Please P t jf SIGNATURE OF TANK OWNER: DATE: OWNER9S PHONE :VOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JAKIARY 1,2005.THE LOCALAGENCY LIST IS AVAILABLE .... ...... 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OFTHE CHANGE.