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a <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:C AAt*J(Si 570C.%C-M J A,QSrf Facility ID#: <br /> Facility Address: 2CCO sr-t M s ON tRA • Reason for Submitting this Form(Check One) <br /> ST ]ocW-rM , CA. R5'-ZOA ❑ Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST ODerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: BF��, A Q I-SON Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): �� 'IY1 <br /> :SNC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: go 6—.6��' OQ M-11'service Technician ❑ Third-Party <br /> International Code Council Certification#: ,�Z.1,2 ^-14 G Expiration Date: <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: 1 1 C HA,Q.L> , tflA-9—A-T'2 Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 4©'C-._�j 5B (�O 6 7 R-.1service Technician ❑ Third-Party <br /> International Code Council Certification#: 524-6837-0,=- Expiration Date: 167-12--.0 <br /> 8 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent 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):, <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 7 —OWNER'S PHONE#: _Cj g- <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/ctipa ag, s htntl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />