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� � RECEIVED <br />JUL 11 2013 <br />owner Statements of Designated underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility ID #: <br />Facility Name: <br />+V, ;t Vj I LC - <br />Facility Address: i 10 0 U-- <br />i <br />X& See ------- w04 Reason for Submitting this Form (Check One) <br />M CA 9 S 3 3 C o Change ofDesignated Operator <br />L <br />Factiity Phone #: <br />3 - 1 x <br />Designated UST Overator(s) for this Facili <br />PRIMARY <br />Designated Operator's Name: Robot Barnhart Relation to UST Facility (Check One) <br />Business Name (if differentfrom above): Reliable Petroleum Services Inc. o Owner E3 operator 0 Employee <br />-Designated Operator's Phone 0: 209-604-9336 X Service Technician 0 Tbird-Party <br />international Code Council Certification #. 5252540 -UC Expiration Date: 0112812014 <br />Designated operator's Name: Guadalupe Sanchez <br />Business Name (If different from above): Reliable Petroleum Services Inc. <br />Designated Operator's Phone #: 209-604-9363 <br />international Code Council Certification #: 5250451 -UC <br />ALTERNATE 2 (Optionat) <br />Designated Operator's Name.., <br />Business Name (Ifdifferenifrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Relation to UST Facility (Check One) <br />[3 Owner E3 Operator 0 Employee <br />X Service Technician 0 Third -Party <br />ExpirationDate; 2-9-T016 <br />----l—Rclation to UST Facility (Check One) <br />a Owner o Operator 13 Employee <br />c3 Service Technician 0 Third -Party <br />Expiration Date: <br />K <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Op tarts). The individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />'Regulations, title 23, section 2715(c) - (f). 6 <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />H <br />.1 S4-q+e- M <br />NAME OF TANK OWNER (Please Print): P -4,A/ L/ <br />SIGNATURE OF TANK OWNER:-. <br />DATE: OWNER'S PRONE #: <br />C's <br />NOTE; 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, ZOOS. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www .waterboards.ca.t ovt!Lqcontacts/cups .says .h[—Tnl- <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />