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Mar. 19 10 10:03a Reliable PetroleumA 0 209-845-8953 p.2 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Facility ID #: Facility Address: Reason for Submitting this —Form {Check one) Facility Phone d X.Change of Designated Operator - 0 Update Certificate Expiration Date Designated UST 0 eratnricl for this PRIMARY Designated Operator's Name: Relation to UST Facility (Check One) Business Name (Ifdfferenj 13 �wmer 0 Operator [3 Employee Designated Operator's Phone ?f: Service Techniciari 0 Third -Party International Code Council Cenifilcation 0-0c, Expiration ALTERNATE I orad Designated Operator's Maine: ess oive Relation to UST Facility (Check Of) Business Name (if df�ftre*,ntfr,0m above). Designated ope or Ph( ❑ Owner 11 Operator 0 Employee Operator's Phone 4: International '11 rica Service Technician 0 Third -Party ode Council Certification Expiration Date: ALTERNATE 2 LOptland) ggz!� Designated Operator's Name: Relation to UST Facility (Check One) Business Name (If dfffereirtfrom above): 0 Owner 13 Operator 0 Employee Designated Operator's Phone #: E— E3 Service Technician o Third -pay Business Code Council Certification Expiration Date: I certify that for the facility indicated at the top p Of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will ji conduct and document Monthly facility inspections and annual facility employee training, in accordancei California Ffrci inspec I Regulations, title 23, Section 2715(c) with C lifo a Code of Furthermore, I understand and am in regulations, and local ordinances) app NAME OF TANK OWNER (Please Print): SIGNATURE OF TANK OWNER: r DATE. OAe lance with the requirements (statutes, to undergroumd storage tanks. 7 NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER AT: B RESOURCES CONTROL BOARD) By JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE zay�;.ittt]11- 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.