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NED APR 2 9 Z009 ENVIRONMENT�EAJH S Owner Statements of Designated Underground Stora gPSW40061 Operator and Understanding of and Compliance with UST Requirements uIi.!LVENa c := 7T - % x�, Facility I D 4: 'kidvss: Reason for Submitting this Foran(Check One) >r,Change of Designated Operator Facility Phone#:(zc 5�i 0 Update Certificate Expiration Date Desi2nated UST QDeratoE(s) for this Facility PRIMARY Designated Operator's Name: —J,-�,-—" Relation to iSTFacilit% (Clieck One) feretaftom above).., Business Name �t — 'eC-I f0if 1 1 0 Owner 0 Operator 0 Employee Designated Operator's Phone 4. 'Dock- (r, nt Ser%ice'reehnician 0 Third-Party International Code Council Certification Sq('} Expiration Date: /---CC ALTERNATE I (Optional) Designated Operator's Name: Relation to UST Facility (Check Q0ne) Business Name(Y'elijferent fi-om above): Designated Operator's Phone#: 0 Owner 0 Operator 0 Employee yee Th 0 Service Technician 0 Third-Party International Code Council Certification#: Expiration Date: ALTERNATE fien(d) Designated Operator's Name: Business Name(,V'dyftrvn1from above): Relation to LIST Facility(Check One) Designated Operator's Phone#: 0 Owner 0 Operator 0 Employee International Code Council Certification 173 Service Technician 0 Third-Party, Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly fiWility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23. section 2715(c) - (f). Furthermore, I understand and am in compl'Inee with the requirements (statutes, regulations, and local ordinances) applic to undergrolkntf storage tanks. NAME OF TANK OWNER(Please Print):- SIGNATURE OF/TANK OWNER: L DATE: OWNER'S PHONE 4: NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY"(NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1,2005. THE LOCAL AGENCY LIST IS AVAILABLE A T: 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANCE.