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10 12:11 p Reliable Petrolei 209-845-8953 p.3 <br />46 <br />*wner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />"A <br />1:4.1cility Narrlr:i 4 3C - <br />Facility ID 4: <br />facility Address 133c) E,• Nlceexn-li-r- "3rvf-- <br />Rtzison ror Submitting this Form t Uwck One) <br />pax6eg;k, CA- o(533(0 <br />0 Change orlkniignated Op=tur <br />Facility Phom- 9: 2,0 !� — Qaz—a <br />X update certiticate i-,viration Date <br />Designated OpendoCs Nanic:m <br />Susinets Name (1fdifferew fi-m ahfptleol <br />Designated Operator's Phone #:2.0cj - <br />Intemational Cock; Courted Ccrtil'icafion 0: <br />ALTERNATE I (00,fmd) <br />Relation to UST Facility Wheek Opw) <br />.per 13 Operator 0 Ernployre <br />Z 3 Service Techniciart 0 Tbird-Party <br />C— I Expiration Date-- 12,- Z.3- 7,01 <br />Designated Operator's Name: <br />Relation to UST Facility (Check. One) <br />0 Owner 13 Operator 0 Employee <br />0 Service Technician 0 Third -party <br />I Business Name Off &1rem-nifrom abowl. <br />otqignated Operator's Phone <br />niernational Code Council Certirkadon #: <br />Expiration Date: <br />Dr.,dgnatcd Operwor's Name: <br />Relation to UST Facility (Check One) <br />0 Owner 0 operator 0 Finployee <br />0 Service Technician 0 Third -Pan) <br />Buziness Nam (#'e�lffercirtfrom abmwk <br />Dr.signated operators Phcmc #: <br />Intemational Code Council C-Crtification #: <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 Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23. section 2715(c) - (f). <br />Furthermore, I understand and am in comp', <br />reg—flation�, 2WElic2Yk <br />NAME OF TANK OWNER (Please Print): -0. <br />i SIGNATURE OF TANK OWNER: <br />OWNER'S <br />DATE: 0 gol 0 <br />.0d <br />with the requirements (statutes, <br />derground storAfe tanks. - <br />MM, <br />-NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: - .- L' �;- �.:, .. �. -: I .... �:': : . <br />WITHIN 30 DAYS <br />OF THE CHANGE. <br />