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Jan 22 10 12:11 p Reliable PetroleumA 10 209-845-8953 p.3 0 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements FA7 Facility Name: S� Facility IDs: �— Facilit% Addr%.ss: 3307 � � Q5{�j�-Z��) .v'z,. VA.X333 Reason lbr Submitting this Form (Check one) ❑ Change ol'Designated Operator X Update Certificate Expiration Date 1'acilky Pl u w 4: 'Z©p(� © 3 Designated UST Operatorts) for this Facility PRIMARY 111% Ucsignated Oper:rtoC s Name: Relation to LIST Facility (Check Ohre) per ❑Operator ❑ Employee :Sen ice Technician ❑ 'bird -Piny Busin�as Name {fJ'rlire nl Imm aLrne 2f 5� 7%G (QLD yyt ted Designated Operatof s Phone +1:20 - ( 0 Lt —CL S 3 (o International Code Council Certification u: %A C) L) C— Expiration [tate: /7-- 7-S- 7,0 1) ALTERNATE 1 (00danal) Designated Operator's Name: Relation to UST Facility (Check- One) 0 Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third-PaAy Busi new Mame t !J &&Term from abow). Designated Operator's Phone -4: Iniennational Code Council Certification #: Expiration Date: ALTERNATE 2 (Opdorwl) Designated Operator's Name: Relation to UST Facility (Check One) 0 Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Business Name (Ifdr_'(Jererrt from above): Designatad Opemloes Phone #: International Code CounciI Certification #: 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 .facility 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 regulations, and local ordinances) app NAME OF TANK OWNER (Please Print): SIGNATURE OF TANK OWNER: DATE:&I . ,94OWNER'S F with the requirements (statutes, nderground stoitje tanks. r ft: -L09- a 5- b 22 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 AT: 2) :'NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANCE.