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Mar 22 07 12: 12p Rff a Test (209) '744-0116 p. 1 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility No=: �_ �__�.�..` V'- y1f~° K1 7177 Facility ID N; <br /> Facility Address: cl u,%- L Reason for submitting this Form(Chuck One) <br /> Charge of Designated Operator <br /> Facility Phone h �{ ®Z- ® `7 ❑ Update Certificate Expiration Date <br /> Dcsianated'USt'Ogerator(si for this Facility <br /> PRIMARY <br /> Designated Operator's Name. ��t � C �_(r Relation to UST Facility(Check One) <br /> Business. Name(Tfdiiorerenf from obuve): A-Pfrp rd a„ --rest ❑ Owncr ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (Z®-4) 7LtqO i Service Tedmician O Third-Parry <br /> Intematinnal Code Council Certification Expiration Date: o g <br /> ALTERNATE I O Marion <br /> Designated Operator's Name: 1�1r. mRelation to UST Facility(Check One) <br /> Business Nam(IfdVerenlfrom above): O Owner Q Operator Q Fmployec <br /> Dcaigmatod Operator's Phone#: ?-0c1 —7 y_V( Service Technician O Third-Party <br /> Intcmadonal Code Council Certification#: f� Za . Hpiration Datc; a <br /> ALTERNATE 2 (Opdomd) <br /> Desivanted Operator's Name: ((elution to UST Facility(Check One) <br /> Bus inemNume(Ifdiffierratfromabove): ❑ Owner O Operator O Employee <br /> Dcaigrwtcd Operntor'a Phone ff: W Service Technician ❑ Third-Party <br /> International Cock Council Cettifiention#: Iricpiration Date: <br /> NOTE:WE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> T.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 271 S(c)-(f). <br /> Furthermore,Y understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)a derground storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE,: �-- 2. 1..— y 7 OWNER'S PRONE#: <br /> r" <br /> November 2004 <br />