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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />11777=1 1 MMIKU=M11m] <br />mg-T-umT ga��z If Relation to UST Facility (Check One) <br />ri[3 r 0 Operator 0 Employee <br />M! 0 Service Technician W'Third-Party <br />�. 10 r 17 1 n 11/1"F7. P "'T <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0__ -Service Technician 0 Third -Party <br />110mri'Mr, L . . . . . . . <br />Reason for Submitting this Form (Check One) <br />0 Change of Designated Operator <br />E) Update Certificate Epiration 2ate <br />RGM7. =i. WIT41'rze T <br />11777=1 1 MMIKU=M11m] <br />mg-T-umT ga��z If Relation to UST Facility (Check One) <br />ri[3 r 0 Operator 0 Employee <br />M! 0 Service Technician W'Third-Party <br />�. 10 r 17 1 n 11/1"F7. P "'T <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />racilX5, 1115i"ttulib YTIT IFLITUVIMMq EmpiTE tri 7=11 <br />Regulations, title 23, section <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAMEOFTANKOWNER <br />OR OWNER'S AGENT (Please Print):3()9)Yo" -3 IM6; H 31111%31 <br />EMM <br />MMUMM <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0__ -Service Technician 0 Third -Party <br />RGM7. =i. WIT41'rze T <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />racilX5, 1115i"ttulib YTIT IFLITUVIMMq EmpiTE tri 7=11 <br />Regulations, title 23, section <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAMEOFTANKOWNER <br />OR OWNER'S AGENT (Please Print):3()9)Yo" -3 IM6; H 31111%31 <br />EMM <br />MMUMM <br />