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i <br /> Owner Statements of Designated Underground Storage Tank (UST) elrator <br /> ' and Understanding of and Compliance with UST Requirement <br /> Facility Name: Facility IDI#: �- <br /> I Facility Address: 1 1 I p i Reasonfo>:I Submitting this Fo (ChLock One) <br /> k Change of Designated erator <br /> Facility Phone# 2� `}� Upd e Certificate Expi tion Date <br /> i <br /> Designated UST Operator($)for this Facility <br /> PRIMARY <br /> Designated Operator'sNamc:Karen R Arnniz Relation to,USTFacility(Che k One) <br /> Business Mame Qf dof rent from above); ❑ Owner Q Operator E I Employee <br /> Designated Operator's Phone#:(209) 518-4836 ❑ Service Technician K bird-Parry <br /> lnteruational Code Council Certification#:8032295-UC Expiration Date:06/2W2011 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: relation tol UST Facility(Che kOne) <br /> Business Name(�fdi}ferewfrom above)- 0 Owner i ❑ Operator Employee <br /> Designated Operator's Phone#: ❑ Service Technician o rd Party <br /> #International Code Council Certification#: Expirationp2te: <br /> ALTERNATE 2 (Opttojiol) <br /> Designated Operator's Name: Relation to'UST Facility(Che kOne.) <br /> Business Name(Ifdi#erent from above), ❑ Owner ❑ Operator Employee <br /> Designated Operator's Phone>#: ❑ Service,Technician ❑ . .bird-Party <br /> International Code Council Certification#: Expiration,Date: <br /> I certify that, for the facility indicated at the top of this page,the indivi4ual(s) listed a ove will <br /> serve as Designated UST Operator(s). T1ie indivtdttal(s)will conduct and document i ionthly <br /> facility inspections and annual facility employee training,in accordance with Califo la Code of <br /> Regulations,title 23, section 2715(c) - (f). <br /> Furthermore,I understand and am in compliance with the requirements (statut , <br /> regulations, and local ordinances)applicable to under ground storage tanks. <br /> NAME OF TANK OWNER(Please Print)- L <br /> SIGNATURE OF TANK OWNER: ZZA_ <br /> l <br /> DATE: 1 O OWNER'S PHONE <br /> i <br /> NOTE: X)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STA. E WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> --. AT: www.N,.,aterboards.ca.eov,'ust/con2acts.cupaa asws.Ittrnl. <br /> 2)NOTWV THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITH 30 DAYS <br /> OF THE CHANGE. <br /> N vember 2004 <br />