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sr <br /> JUL 28 2 <br /> Owner Statements of Designated Underground Storage Tank(USTAkwl or <br /> u <br /> jr FiLc <br /> and Understanding of and Compliance with UST Requireme4,00�,v <br /> tiq couw <br /> 'THIIEPARTkA. <br /> FacilityName: racility ll)#. <br /> FacU Ad <br /> 35 45�-Wa4trld rck lk-zon for SuNnitting this Form(Check One) <br /> Change of Designated Opei-utor <br /> Fli(y Phone it X Update Citt-tificutAc Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> -Desipated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(Vdifflrete froin above); 0 Owncy 0 Operator 0 Employee <br /> Designated Operator's Phone 4:(209)51-84836 0 Servico Twimician. X Third-Party <br /> International Code Council cotification#..9032295-UC Expiration Date:06/11/2013 <br /> ALTERNATE 1��vnqQ <br /> Designated Operator's Name, Relation to U-STFacility(Check-One) <br /> Business Name(If differentfroat above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone 0: 0 Service Technician 0 Third-Parly <br /> #1hLearational Code Council Ceitific-dtion;0: Expiration Date: <br /> ALTERNA3'E 2 (optional) <br /> IXsignated Operator's Name- Relation to UST Facility(Check One) <br /> Business Name(11dijjerentfirom above); 13 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#; 0 Service'Technician 0 Third-Party <br /> International Coda 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 Mumal.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) applicahle to underground storage tanks. <br /> NAME OF TANK OWN-Ell(Please Print):_.IjIA 7erRl.no i) <br /> SIGNATURE"OF TANK OWNER: <br /> DATE: OWNER'S PRONE#:_!%1'6 <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. vatei-boar(Is.Ca.gOV/L[St/C011taCl /cups agvs,hvnl. <br /> 2)NOTIFy THE LOCAL AGENCY OF ANY CHANGES 1'0 THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGIE. <br /> November 2004 <br />