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;!lay 24 11 11:27a Reliable PetroleumA 209-845-8953 p.2 <br />Owneretnents of Designated Underground Storage Tank (UST) Operator <br />an Understanding of and Compliance with UST Requirements <br />Facility Name: A od j Vv—e7 <br />Facility ID =: <br />Facility Address: SG pLLe <br />Reason for Submitting this Form (Check One} <br />hange of Designated Operator <br />Certificate Expiration Date <br />Facility Phone #: `_ 2 G Z <br />Designated UST ORerator(s) for this Facility <br />01 IVIAUV <br />Designated Operato 's Name: Robert Barnhart <br />Business Name Qfc ffierantfrom above): Reliable Perroleum Services Inc. <br />Relation to UST Facility (Check One) <br />❑ Oumer 0 Operator -3 Emplo}ee <br />X Service Technician 7 Third -Part <br />Designated Operato s Phone #: 209-604-9336 <br />International Code Puncii Certification #: 52525 40-TiC <br />Expiration Date: 12-23-2011 <br />ALTERNATE I ( <br />tonal) <br />Designated Operato 's Name: Guadalupe Sanchez <br />Relation to UST Facility (Check One) <br />Business Name (1f <br />erent from above): ReRaNe Petroleun: Services Inc. <br />p Owner 0 Operator <br />0 Empio} ee <br />Designated Operato <br />'s Phone #: 209-604-9363 <br />X Service Technician C <br />Third -Pam' <br />International Code <br />ouncii Certification #: 5250451 -UC <br />Expiration Date: 01-29-2013 <br />ALTERNATE 2 ( <br />bona!) <br />Designated Operato <br />s Name: <br />Relation to UIST Facility (Check One; <br />Business Name (Iferent <br />from above): <br />:1 Owner G Operator <br />0 Employee <br />Designated Operato <br />'s Phone #: <br />© Service Technician ❑ <br />Third -Parts' <br />International Code <br />unci] Certification n: <br />Expiration Date: <br />j <br />I certify that, fc the facility indicated at the top of this page, the individuals) listed above rill <br />serve as Desigr ated UST Operator(s), The individuals) XN111 conduct and document monthly <br />facility inspections and annual facility employee training, in accordance NAth California Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore,'understand and aim in compliance with the requirements (statutes, <br />regulations, ar d local ordinances) applies laderground storage tanks. <br />NAME OF TALI OWNER (Please Print): k _ � %V � L— . E (-8 &`� <br />SIGNATURE Of TANK OWNER: vL <br />DATE: • 511,31.24 ! % OWNER'S PHONE 67 <br />NOTE: 1) SUBMfT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES C(INTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: wnviv.waterb rds.ca.a*ovlustleontacts/ciina a�-s html_ <br />2) NOTIFY THE CAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHAN . <br />November 2004 <br />