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� 3 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and. Understanding of and Compliance with UST Requirements <br />ffFacilityPhone <br />hell Facility in #: <br />341 E Maur Reason for Submitting this Form (Cheek One) <br />Ripon, CA, 95366 X Ch a of Deni ated <br />ang gn Operator <br />(209) 559-4544 ❑ Update Certificate Fxputtion .Date <br />DesignaW UST O erato s for this Facili <br />P Y <br />Designated Operator's Name: Karen R Arnaiz Relation to UST p$cility (Check One) <br />Business Name Qf d�erent from above): 0 Owner 0 Operator o Employee <br />Designated Operator's phone #: (209) 5184836 O Service Technician X 'Third Party <br />International Cotte Council Certification #: 5266643 -UC <br />Designated Operator's Name: <br />Business Name (ffdi.,(jerent from abnve): <br />Designated Operator's Phone #, <br />International Code Council Certification #: <br />ALTERNATE 2 (Optional') <br />Designated. Operator's Name: <br />— B i Name (!f djff~nr from above): <br />Designated is Phone #: <br />International Code Council Certification #: <br />Expiration bate: 07/16/09 <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator ❑ Employee <br />Q SMice Technician 0 Third -Party <br />.Expiration Date: <br />Relation to UST Facility (Check One) <br />* Owner ❑ Operator Q Employee <br />* Service 'Technician 0 Tbird-Party <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 USTOperator(s). The individual(s) will conduct and document monthly <br />facility inspeetions and annual facility employee trainIng, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />re tions, and lord ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please 1Prino.—} ' ft L" f� '?'.1— 4--ry 6 L.0 <br />TA II,lr eAAe— <br />NOTE: 1) SUMMIT TETIS COMPLETED FORM TO THE LOCAL AGENCY (NOT I'M STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2M. THE LOCAL AGENCY ILtST 1S AVAILABLE <br />AT; www. waterboards ca Dov/ust/cantacts/cup�geys html. <br />2) NOTIFY TfW LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />Noverttber 2004 <br />