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MN Owner Statements of Designated Underground Storage { ir and Understanding of and Compliance with UST Re )jqur� t .r.3 Facility Name: BP 06080 Facility ID: 06080 NOV 2 2 Facility Address: 85 E LOUISE AVENUE Reason for Submitt' this Fm (Check One) LATH ROP,CA 95330 ■ Change of Desi"r�gt1� or Jv� � ; C' L ,� Facility Phone#: 2099839144 ElUpdated CertiWR9thwtIbAjPAtP Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Justin Downs Relation to the UST Facility(Check One) Business Name (If different from above): Belshire Environmental Services, Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ■ Third-Party International Code Council Certification#: 8021990-UC Expiration Date: 12/7/2012 ALTERNATEI Designated Operator's Name: refer to backup document I Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: refer to backup document I ❑ Service Technician ■ Third-Party International Code Council Certification* refer to backup document Expiration Date: refer to backup document ALTERNATE Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name (If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification* refer to backup document Expiration Date: refer to backup document certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve 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 Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Rich Gossett Signature of Tank Owner: Date: 11/15/2011 Owner's Phone #: (714) 670-3958 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:www.waterboards.ca.gov/ust/contacts/cupa_agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.