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ALM 22 12 01:40p Reliable Petroleun-A 209-845-8953 p.2 <br />1 0 Is <br />Facility Name: <br />Facilitv Address: <br />Kwility Phone #: <br />'atements of Designated Underground Storage Tank (UST) Operator <br />d Understan'ding of and Compliance with UST Requirements <br />Faci I ity I D <br />F? oc) Reason for Submittin-g--this Form this ork,) <br />Change <br />-7 0 Update CL <br />of Designated Operator <br />-airicate Expiration Date <br />-7 1, <br />.PRIMARY_ <br />Designated Operal. is Name: <br />Business Name (ifj1ffev,jj-,, <br />Designated UST 4ror this Facilitv <br />i� <br />above): <br />=19naLed Operati Cs Phone 4: <br />�q <br />International Code <br />ouncjl Certification <br />ALTERINATE1 <br />0Bonet ) <br />Designated Operati: <br />Name: <br />Business Name rewfrom above).. <br />Designated Operas <br />s Phone 4: <br />Inlern,ational Code <br />Ouncil Cerlification <br />ALTERNAT 2 <br />Designated Operato 's Name: <br />ess <br />Blumsinemss Name (If <br />retztfromabove); <br />Designated operato <br />)Per 10 <br />s Phone <br />Tn �o <br />International Code <br />, r <br />ci I Cert'. <br />nci(Certirication <br />'cation 4: <br />Relation to Ur,,'r Facility (Che,.h one) <br />11 Owner C1 Operator 0 rmPj0y'e <br />c Operator <br />42C>4 q .3 (o Service Technician 13 Third -l?", <br />tj�� - �tl: ❑ Th <br />Q (1- Expiration Date:0 1 -1q <br />- 9� <br />CL4- Relation to UST Facility (Check One) <br />Owner 0 Operator Cj Employee <br />JV Service Technician E] Third -Party <br />Expiration Date: <br />Relation to U917 Facility (Check One) .— <br />El Owner Ci Operator 0 F-mpjuyee <br />C Service Technician 11 Third -Party <br />Fxpiration Date: <br />I certify that, fo. - the facility indicated at the top of this Page, the individual(s) listed above will <br />sen,e as Design ited UST Operator(s). The individual(s) wifl conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, section 2715(le) - (f) - <br />Furthermore, I understand and am in <br />regulations, anti compliance with the requirements (statutes, <br />local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): <br />SIGNATURE OF ''ANK OWNER t <br />-T '24 '- 17-, <br />DATE- OWNER'S PHONE #: --7 <br />(VOTE: 1) SUBMI THIS COIM'PLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CO, TROL BOARD) BY JANUARY 1, 22-9. THE LOCAL AGENCY <br />LIST IS AVAILABLE <br />21) NOTIFY THE LJ)CAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE1 <br />