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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: CAAQw G S TOC.1(T®w A AS Y Facility ID#: <br /> Facility Address: 2®®a �-�-'M SG f2 p Reason for Submitting this Form(Check One) <br /> STOC ICT®N CA. g,3 ?of. ❑ Change of Designated Operator <br /> Facility Phone#: wr Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: WC q,4 L/A4D p Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): �,�j�/�< ;r <br /> ,�/t/C, ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 80E 658 O®�� No"Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5z 46V.965 "GLC Expiration Date: 01—/0-09 <br /> ALTERNATE 1 (Optional <br /> Designated Operator's Name: C 144 I Iry eA E X 91 WA Relation to UST Facility(Check One) <br /> Business Name(If different from above):• ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 95—65-8--00 6 Service Technician ❑ Third-Party <br /> International Code Council Certification#: 2 9 746_u G Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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 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)- , Q _ <br /> SIGNATURE OF TANK OWNER: <br /> DATE: _` f OWNE 'S PHONE#: _�nj'j Qi _ �t 5�' 7-,�l <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/ust/contaCtS/cepa ags�htmh <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />