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a <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and 1 inderstanding of and Compliance with UST Requirements <br /> —" Facility ID#: <br /> Facility Name: ,i ,2�C` 6.,�. <br /> Facility Address: 15,6"/:? Reason for Submitting this Form(Check One) <br /> 2 Change of Designated Operator <br /> ❑ Update Certificate Expiration Date <br /> Facility Phone#: <br /> Desiignated UST Operato (s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:B r u c e N . H o a g 1 a n d Relation to UST Facility(Check One) <br /> Business Name(If di&rent from aboveT.£'c h 1 a n d T e s t i n g , I n ❑ Owner ❑ Operator O Employee <br /> Designated Operator's Phone 0. �`-. 7 2 <br /> 4-9420 Service Technician ❑ Third-Party <br /> International Code Council Certification#:6 246932-UCP Expiration Date: 11-19–2 0 0 6 <br /> ALTERNATE 1�7!ona!) <br /> Designated Operator's Name:,,G a r y B o s t r o m Relation to UST Facility(Check One) <br /> Business Name(If di,rent frorn above):T e t d l 1 a n d •T e s t i n I n ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's,Phone#:2 0 9,--7 2 4—9 4 2 0 Service Technician ❑ Third-Party <br /> International Code Council CertificatioBOK 0 O O 14 Expiration Dat 12-01-2 0 0 6 <br /> ALTERNATE 2 (Opirional) <br /> Designated Operator's Name: Carlo H De La Fuente Relation to UST Facility(Check One) <br /> Business Name(!f dW4rent from above;),Same as above ❑ Owner ff Operator ❑ Employee <br /> " c ❑ Service Technician ❑ Third-Party <br /> Designated Operator t;Phone#: c _ <br /> International Code Council Certification#: 5273901—UC Expiration Date: 12®21'2 007 <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designstcd UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspectic,xis and annual facility employee training,in accordance with California Code of <br /> Regulations,title:.23, section:Z715(c)-M <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): it <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.waterbotlyds-ca.eov/ustl�^ontacts/cuna as sy-html. <br /> 2)NOTIFY THE VOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />