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t <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> .._......_.— __ _.__ _..s... _..._. <br /> Facillt�+Name <br /> Fa_..c,_►_i. .__. . ,�.�.....-oL ...`-._.-rq.- .. . Reason <br /> fr Shu._.. .ts <br /> lyAs; ! Fm.1.Cck <br /> .. .. .� � . ...r <br /> )6 Chaaw ofnesrl 1 <br /> updat Certifica! Fx ' -oo Date _ - <br /> � l�sdli Pharte#• � �_ --- �� -�-�----�� <br /> Designated UST ODerstorM for 1WER-C <br /> PRiMAIt"Y - <br /> De sipamted Qtyerator's Name' � d K! T(Q 5 b l.A. __... li elation to UST Facili Check—Ow <br /> Business Name(!f d{ i eiu Eras above): I C] Ownrx C7 !7 En'p�°�" ..... <br /> O_Service redmidart <br /> wed O torr s Phor:e#: 9 14 - $Z..l�t 1..�' '7 to <br /> _.... . _.,_ ..•...._. _........................ ......._- _ on Date: r <br /> lntOrnatiortal Code CMMCit Certifie tiot►#• ,�„O <br /> ALTERNATE 1(O�ou+t) ....__:,.,.�._,....-- <br /> DcsignMd esNam: ._.�.---_--- Relation to i7ST Facili Check ane <br /> _ <br /> Business Name cl +rrirtro�m above: © Owns „CI_Operator <br /> _ .. <br /> 0 _S=VMTeetmici� vio:'Thlyd-Parte �__ - --- -------�— - <br /> Desi OQeratar's Phone#: _... . _.... <br /> -_.......................... F 'ration Date: <br /> lnternatiar�Code Council Certification#• ----•--. <br /> ALTERNATE 2_L <br /> Desi star's Name._ Relation to UST Fadlity Check One1 <br /> �. <br /> � ........ fir..,._.. ... .... _._.. .._.. __ ... _. ... .._. n ... .Business Now ' Brent F above): _.......,,._........ ..... ......................... ...._.. ..._.._._ ,__... ......_...... <br /> ❑ p�,� p Qperatar -O Em loyrc <br /> o Service Tedmicisn o Third-Party --- <br /> besi ted Operator's Mmme#: _....._.... -— - .....__.. _ ........ ......__.,.,- .... ......__.._. _.... _ <br /> _...._.... ........__..._..._,.... .._.,....._. Expiration Dater <br /> Intetnat Cody Council Certificatiat#• _ <br /> I certify that,for the facility indicated at the top of this page,the ixldividuai(s)listed above will <br /> serve as Designated UST Operator(s). The individual(s)'wM conduct and document nzont* <br /> ns and annual facility'employee training, in ac <br /> facility inspections cordance with California Code of <br /> Regulations,We 23, section 2915(c)-(). <br /> Furtbermor�e,I understand and am in eouspiiaucc witk the requirements(statutes, <br /> regulations,and local ordinances)applieable to underground storage tanks. <br /> NAME OF TANK OWNER(Mom Print): 1'�� � �A M C 1 IYI A fi <br /> SIGNATURE OF TANK OWNER:� ' r Vitt�'P nn <br /> DATE: y a S OWNERS PHONE : ��• 9 - "7 S a l <br /> NOTE: I)SUBMIT THIS COMPLETED FORMOTS THE LOCALCY(NOT AGENCY HE ST THE WATER <br /> RESOURCES CONTROL BOARD)By JANUARY� ont ts/ s.htt� <br /> AVAILABLE AT:MMA csboeOy — ' <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INIrolt'.MATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br />