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f `1 <br /> Lox <br /> owner Statements of Designated Underground Storage Tank(UST) Ope WW15 2010 <br /> and Understanding of and Compliance with UST Requirements � <br /> d' 9�J'e. £' <br /> L®44 1 <br /> Faculty]D#, <br /> F2cAtityName _{ this Form CheckC3ne�, t�lEfT <br /> Facility Address: tf y�( a(R Rtsson far St btnitting <br /> yC Change of Designated <br /> Updgee certificate Expirati s►Date <br /> Fatuity Phone it <br /> Designated UST ratar(sl for this Faei' <br /> PRIMARY Relation De <br /> to qST Facility(Cheek ) <br /> pesipated open war,Nmue.Karen R Arnalz <br /> Busiacss fiistne(�1 different from above): d Owner ❑ Operator d Employee <br /> sigr, OP 's Phone#t(209)51 ❑ Setviccehniciata darty <br /> Intm.tional code council certification#:8032295-UC Expiration De:06/20/201 <br /> ALTERNATE I tonal <br /> Designated Operator's Nettle: Relation to Facility(Chet One) <br /> Bmiinem Name UT from above): ❑ Owner � ❑ opanW ❑ Employco <br /> Designated Openttor's Phone#: ❑ Service Technician ❑ ird Parry <br /> #International Code Council Certification#: Expiration Date: <br /> i <br /> A[.x RNA's 1 2 (.00deno <br /> rDesignatod <br /> 's Name: <br /> Relatio�a to UST Facility(Che One) <br /> �-- (II&fferemt from above): ❑ Owner ! ❑ r Employee <br /> zmtor's Phone ❑ Servisx(I ec�aician ❑ ltd- Yode Council Certification#: Expiratioaa Date. <br /> a <br /> I certify that,for the facility indicated at the top of this the individual(s) listed ove Will e, ' <br /> tWy <br /> serve as Designated UST ppCrator(s)_ The indiv'dual(s)Will conduct <br /> and document a Cod <br /> facility inspections and amuual facility employee g,in acc�ordane with Califo a Code of <br /> Regulations,title 23,section 2715(c)-(#). <br /> Furthermore,I•understand and am in compliance with the requirements(Statuto s, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please t): SSSP� ry jrf 1 1. <br /> SIGNATURE OF TANK OWNER' <br /> DATE: 1 �I OWNERS PHONE#: <br /> NOTE.1)SUBMIT CO TED FORM TO Z005LTHE LOCAL GI*OT THE SV T <br /> E WATER <br /> ENCY LIST IS YAIL BLE <br /> RESOURCES CONTROL BOARD)BY JANUARY 1, <br /> AT: www.waterboards.ea. ov;ust!cofltactsicu a s.herrt. <br /> �)I�TOTIFY LOCAL AGENCY OF'ANX GES TOTINFORMATION� WIT 30 DAYS <br /> OF THE GE- <br /> ovember 2004 <br />