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Jan 22.10 12:12p Reliable PetroleumA 10 209-845-8953 p.4 16 Owner Statements of designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements _ C , l � dtTll. -AI -ac -:i a + Fucilit) Phone M: h —47— YDYo Se W1 i C- r -o- Ga _C A, 15 Reauln for Submitting this Form (C7reck ()nr% AK ('hange Of llesi,nuted ()pe .!tor ❑ Updatc Certificate firpiration Date PIiI,lrDesi nated UST fJ erntor s for than ilitv ARY [)CSignated OperatoCsNzinee: Businchs Ntune (/f ch'f/i n'tr/ %rout uhur.'r} tLme W -- ' `able 47 t lksiQiaated Operator's Phone N: 7� 60 a g33u Intemational Code Council C ertificatiun it: $Z sz,S yti^u -ALTEPUN ATE I ffl !tats-- LDasignated Operator's Name: siness Name ({f df#en'nt fr om above): rhsignated Operator's Phone : International Codc Council C.ertiticateon #: :%LTER!NATE 2 (0pfiondj Designated Operator's Name: --------- Business' W diO'Alrt fr nm ab.ve): ..... _ L)rsignatgd Operator's Phone a: ---- International International Code Council Certification.4: Relation to t.is-r Facility (f we—vh Oru•) .❑ Owter ❑ Operator ❑ f mployee bC 3erNice Tcc:hnician ❑ Third -Party Expiration [late: (�►- z 3 sa 1 Relation to I:ST Facility ((:hvc-k Unc) ❑ ()1vncr C Operalur C EnTploye t D Service Technician 0 I`hird.Party Expiration Late: Relation to L(ST Facility (Clacek on") ❑ Owner ❑ 0perator ❑ Employee 0 Sereice Technician G Third -Parte Fxpimtion Date: Y certifv that, for the facility indicated at the top of this page, the individual(s) listed above will sen -e as Designated UST Operator(s). The individuals) wilt conduct and document monthly facility inspections and annual facilit, employee training, to accordance With California Code of Regulations, title 23, section 2715(c) 11 Furthermore, I understand and ane in compliance with the requirements (s regulations, and local ordinances) applicable to underground storage tanksrAtutes, NA,LME OF TANK OWNER (Please Print): SIGNATURE OF TANK OWNER: i f DATE: i �i i (: OVV*NER'S PHONE�-- NOTE: 1) SUBMIT *'His COMPLETED F'ORNI TO THE LOCAL AGENCY (`OT THE STATE VtihTERRESOURCES CONTROL BOARD) BYJA�UARY r, 2005,TE LnCALAG;tiC� LIST I.S A`'AILABI.E 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFOR.NIATION WITHIN 30 DAYS OF THE CHANGE.