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Ll <br />n <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Alz, 10 <br />V .,. <br />Facility ID #: <br />Facility Address:, ® <br />(�� �,� �_� 4 , <br />Reason for Submitting this Form (Check One) <br />—=, � of "or\ <br />l� C- 6 " a <br />19 Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: "Lam( C 12 - b.5 " A - 6t_ fj .30, t- <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Richard MAERTZ <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): TANK TEAM. INC. <br />Designated Operator's Phone #: 805-658-0067 <br />International Code Council Certification #: 5243837 -UC <br />Expiration Date: Oct. 12, 2006 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Hector GALINDO <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If differentfrom above): TANK TEAM, INC. <br />Designated Operator's Phone #: 805-658-0067 <br />International Code Council Certification #: 5248963 -UC <br />Expiration Date: Jan. 10, 2007 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Bernard OLSON <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): TANK TEAM, INC. <br />Designated Operator's Phone #: 805-658-0067 <br />International Code Council Certification #: 5252993 -UC <br />Expiration Date: Jan. 21, 2007 <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 2715(c) - (f). <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): % �1r�ri �7�T4 <br />SIGNATURE OF TANK OWNER: <br />DATE: OWNER'S PHONE #:� <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca.gov/tist/contacts/cupa ag s.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />