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May 10 12 02:20p Reliable PetroleurnA <br />209-845-8953 p.3 <br />0�► <br />Owner Ratements of Designated Underground Storage Tank (UST) Operator <br />ar. d Understanding of and Compliance with IST RequIrements <br />Facility Name: G. S DEPOT <br />Facility ID #: <br />Facility .Address: 1330 E. Yosemite Avenue I , &4anteca CA 95336 <br />Romn for SubmittingthisForm �(Cheek ore) <br />0 Change of Designated Operator <br />Facility Phone 4: 2 )9-825-0332 <br />X Update Certificate Expiration Date. <br />Designated LUST Qpem!o-r(s) <br />far thls Facility <br />PFUNIARY <br />Designated Operas ur's Dame: Robert Barnhart <br />Barnhart <br />Relation to CST Facility (Check- One) <br />Business Name (tf fifferentfrom above). -Reliable Petroleum Senqces Inc. <br />ces <br />Owner <br />0 0 'n Operator <br />0 Owmer 13 Operator 0 Employee <br />Cla 'Ploy' <br />Designated Operas r's, Phone <br />s ph n 209-604-9336 <br />X i Th, <br />X Service Technician 11 Third -Party <br />n <br />sc� ce Technician t] rd -Party <br />International 0 <br />International Code Council Certification 4: 5252540 -UC <br />Expiration <br />Expiration Date: 01/28i2014 <br />'2 <br />ALTERNATE I tionad <br />Designated Operator's Name: Guadalupe Sanchez <br />Relation to UST Facility (Check One) <br />Business Name (ff&f(crenifrom abole): Reliable Petroleum Services Inc, <br />:1 Owner 13 Operator 11 Employee <br />I Designated Operato -'s Phone #: 209-604-9363 <br />X ScrviceTcchnician 13 Third -Party <br />International Code ffouncil Certification 4: 5250451 -UC <br />Expiration Date: 01/29/2013 <br />ALTERNATE 2 (Optional)_ <br />Designated OperatofsName: <br />Relation US <br />Relation to UST Facility (Ci?eck one) <br />he❑ " <br />3u 'rd <br />Business Name (Ifd jerenj)�om above): <br />�CkE <br />Designated Opicratol's Phone #: <br />0 Owner 0 Operator <br />0 Owner 0 Operator 0 Employee <br />'Service <br />1:1 Technician 0 Third -Party <br />International Code Council Certirication#: <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 Design ited UST Operator(s). The individual(s) <br />will conduct and document monthly <br />facility inspect/ ns and annual facility employee training, in accordance with California Code of <br />Regulations, tit' 23, section 2715(c) - (f). <br />If <br />Furthermore,understand and am in <br />regulations, an local ordinances) app] <br />NAME OFTANOWNER (Please Print): <br />SfGNATURE OFTANK OWNER: <br />DATE: 0i — <br />�7 2,0) 4 --OWNER'S <br />ance with the requirements (statutes, <br />to undergr un storage tanks. <br />Z <br />Ph <br />NOTE: 1) SLI"BM)t THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES COTROL BOARD) BY JANUARY 1, 2005- THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterhonlrd- rq <br />jM0CAL AGENCY OF ANY CHANG "I'll 6 <br />11my: 6 UnZjjy-.t <br />November 2004 <br />