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Owner Statements of Designated Underground Storage Tank (UST) Opeg�2 8 2004 <br />and Understanding of and Compliance with UST Requirements NWi x <br />Facility Name: 1 L4h,{,At)S O lL — .. Ckj�_ P <br />Facility ID <br />Facility Address: 1 e{ 9j <br />Reason for Submitting this Form (Check One) <br />La' Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: M ' -71 ® 1 0 <br />Desienated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: lbr,% <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 416�,� .• �,� <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: „�v V®� p �� �p <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: dj (b ?j:5LkS:" <br />International Code Council Certification #: ]�%3�0 (pStOt — vim, <br />Expiration Date: (� /1 (fib <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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 <br />SIGNATURE OF TANK OWNER: <br />DATE: it (1,1104 OWNER'S PHONE #: 616) W j - :&,;- p <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/cgpa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />