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FROM :B.Z.SERV I CE"STAT I ON MAI N "E FAX NO, ;91S 371 2540 13 2006 04:05PM ia3 <br /> Owner Statements of Designated Underground Storage T (UST)Operator <br /> and underu&uding of and Compl is noo with f 1ST Roquirememts <br /> 'p.G:llty : � •,. .�;.� P�0 ro tri ..�__. , <br /> Wffiy <br /> Addrmt; Roves tirr SW=tiws tLi;s,Nam Check Jno) <br /> p Gyrelt�e ufDatjwled Clpcwty <br /> Nwiliy Pht+na M G U 10 Certiilooto 3tpiration Dew <br /> t <br /> 17alpmtt (7(w*ata a Nwnv Nolstkan tot 8I'I=�ittty(Cl�tak O�rc) <br /> I Rtnlmrie Nunn(lfs�jp3rsau ora atx. J; ';a. '�1" Rttat 0 opareks* © Employed <br /> ha 9sry a Tedrniassrr 0 l?.00-Pa`rty�� <br /> cad Crpstesa•'a Ph�c N; /� - '� ' .� a:a ^I <br /> lntnaeliae!I Cv1k 00=1 oerdflogoo 11: ExpirWoo Dan: _ <br /> A a C R 1 40 <br /> Dalpated Opomtin's Name: Aaladatt b UST FLM Mty(C'h"k 0") <br /> Rues Nacee((fAffiftWfMW ah—): 0 0 a owstor Q F-00yoo <br /> DWIPO .w Pkane M: ® 90tviac"eckaascsar O�1b1tA-Party <br /> JaMmUftod trade Ckn>;e®Il CerlinoatiM N EImk3n Dept <br /> ALTERNATR 1 <br /> OwWwad( antdt's Name: ! Rdetian to UST Fnctlity(Chrrak n„e) <br /> D Nome((} nt fives A&W' _ U r ® Operator ® &mriny- <br /> DeslFtala4 dw's Phrmo M; _.. . in Hervies T as 0 'Third-Fatty <br /> kkumatiml *' �. k <br /> NOM THR UWAL REGUI ATORY AGENCY MUST BR NOTWMD OF AANY MANGES TO Tt is <br /> IIt MjtMATIOPt Wl'lCM 70 DAYS OF TIB CHANGA. <br /> I certify that,for the facility indimWd at Ow top oftl:ia page,the iudividual(s)listed above will <br /> scrvc as Designeted UST or(s), Tho ind,.viduuel(s)will conduct and document monthly <br /> facility ins is and annual'facility employee training,hi socmdanec with California Code of <br /> Regulations.title 23,wotion 2715(c)-(f), <br /> Fortbermarer I understand and am in Compliance with the requirements(StAt"tes, <br /> regulations,and local tardinsacm)appileable to underground storage tanks. <br /> NAlIItE OF TAM JK O S r 1Z-t>owr <br /> ON OWNER'S A(yl?NT anwe tMa9! S I- <br /> SIGNATt1RR OF TANK - <br /> OW MM OR OWN1911R's AGRN'!tt <br /> DATE: ,'L 1 '>` ,OWiYU-Si MONK 0. <br /> Svptmlw 2034 <br /> Z0 39dd 09N3Nd3A VSI-1 LZLb6EE60Z 9E:9T 9002/ET/ZT <br />