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A - <br />La• <br />Owner Statements of Designated Underground Storage Tank (UST) Operator;­�, <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: _4jV V L <br />Facility ID #: <br />Facility Address: 3q I C 0— <br />Reason for Submitting this Form (Check One) <br />or" q4��15� <br />Change of Designated Opff,46) L7�, (r--,� i - <br />- I j 7_1 <br />X Update Certificate Expirat I L, = <br />Facility Phone # <br />Designated UST Operator(s) for this Facility A1JG ',-' b , _J <br />Designated Operator's Name: Karen R Arnaiz <br />Relation to UST Facility (Check <br />0 Owner 0 Operator El Employee <br />0 Service Technician X Thir&Party, <br />Business Name Qfdifferentfrom above): <br />Designated Operator's Phone #: (209) 518-4836 <br />International Code Council Certification #: 8032295 -UC <br />Expiration Date: 06/20/2011 <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />El Service Technician 0 Third -Party <br />Business Name (Ifdifferentfrom above): <br />Designated Operator's Phone #: <br />#Intemational Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Opdonal) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0 Service Technician 0 Third -Party <br />Business Name (ffdifferentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification 4: <br />Expiration Date: <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 Operator(s). 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 <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print <br />14ES011RCES CIVAMMIL BIWAiii 91 3,M111"'If 1, 2005. hJ' IS AAT AILAIME <br />i I 111` 1 ; 11 ill;q I 'IIII'1111��Iqsl­i Ill gi, "I'll,• 1711 <br />111 11311! "I'll, III <br />MIM 11H DK a *I F -110M <br />November 2004 <br />