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RECEIVED <br /> JA <br /> Owner Statements of Designated Underground Storage Tank(UST)OpeNr , 2011 <br /> and Understanding of and Compliance with UST ReVirenVOoNMENTAL HEALTH <br /> PE <br /> Facility Nam= Facility ID#:vt& 1 6) <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> Change of Designated Operator <br /> Facc�ity Phone#: 13 Update Certificate Expiration Date <br /> Designated UST Oneratorfsl for this bLdiiv <br /> PRIMARY <br /> I)esignabed �(Jydffi�rerewfrom <br /> : � � (�{ Relation to UST Faality(Check One) <br /> Business Name above): <br /> 13 Owner ❑ Operator ❑ FmPI°Yce <br /> Designated Operator's Phone#: — <br /> ❑ Service Technician %ThJh44 q <br /> Intematimal Code Council Cextifcadon#: 67 Expiration Dater <br /> ALTERNATEI <br /> Designated Operator's Namec Relation to UST Facility(Check One) <br /> Business Naomi(fldffefrom above)- ❑ Owner ❑ Operator ❑ EmPI°yee <br /> Designated Operator's Plane#: <br /> ❑ Service Technician ❑ Thircl-Party <br /> International Code CbwmR Cext na#: Expiration.Date: <br /> ALTERNATE 2 ( <br /> Rela <br /> �g �opexatoesName: Relation In UST Faetht'y(Check One) <br /> Business Name(zr&erent from above)- ❑ Owner ❑ Operator ❑ Employce <br /> 5A igaaved opexawes Phone#: ❑ Service Technician ❑ Thkd4larty <br /> International Code Council Certificutian#: Fxpiration Date <br /> I certify that,for the facility indicated at the top of ibis page,the individua(s)listed above will <br /> serve as Designated UST Operator(s)- The individual(s)will conduct and document montbly <br /> facility inspections and am►ual facility employee training,in accordance with California Code of <br /> Regulations,title 23,section 2715(c)-(t). <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(Plem print): II ��- Iti1 I S S C 14 <br /> SIGNATURE OF TANK OWNER: �— <br /> DATE•` OwNEWSPHONE#: <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE FOCAL AGENCY LIST IS AVAILABLE <br /> AT:vt ww waterboards ca eov/ust/cOntacts/cuna Agys tltln" <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WrIMN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />