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02/11/2007 15:25 12099519707 FIRST EVERGREEN OIL PAGE 02/03 <br /> 0 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Under" ding of and Compliance with UST Requirements <br /> Facility Name: Fam1w JD <br /> Facility A&hxuss! I(a Rca3oa for SWmaitting this Form(check One) <br /> t' <br /> iE�. A VA Q Omp of Designated Opendw <br /> Facility Phone# X Update Certificate Expiration Date <br /> Des" „,ted UST22gStor(s foie r this Facility <br /> Rx <br /> Designate�operatees-Name:Karen R Arnaft Relation to UST Facility(Check One) <br /> Business Name(tfdoierentfrom above): 0 Owner 0 OperMr 0 EmpJQy" <br /> Lteesi 's Phone#-.(209)518-4836 0 Service TecWc1= X. Third-Party <br /> intmAtionai code,council Certification#.8032295-UC Expiration Date-06/20/2011 <br /> ALTERNATZ J.fflZj4 <br /> Designated OperaWs Name- Relation to UST Facility(Check One) <br /> Business Name(11differentfrom above): C3 Owncr 0 opeMtDr Q Employee <br /> D=igawad Operatoes Phone 0 Service Technician 0 Third Peaty <br /> #IUMM94onal Cock Council Certification Expiration Dft. <br /> ALTERNATE 2 (0 <br /> Designated Operator?s Name: Relation to UST Facility(Check One) <br /> Business Name(.(f AO} rent from above)- 0 Owner 0 Op"ator C3 Employee <br /> DeshmatBd Operator's Phone#; 0 Service Technician 0 Third-Party <br /> Intcmational Code Council Certification 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 doomient monthly <br /> facility inspecdons and annual facility employee training,m accordance with California Code of <br /> Re "ons,title 23, section 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulatiew,and local ordmiances)applicable to underground storage tanks. <br /> NANM OF TANK OWNER(Pleme Print); n 421R <br /> TAA L I I 3&IA Lid <br /> SIGNATURE OFT OWNER: <br /> ]DATE: OWNER'S PHONE#: '9 AV <br /> NOTE: 1)SUBMIT TMS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JAMARY 1,200.THE LOCAL AGENCY LIST LS AVAILABLE <br /> A��.,1152yw =dsx�a. yh�'p,,,%�emcu j�a *s.l�,,nL <br /> �.walerb� <br /> 2)NO TWV THE LOCAL AGENCY OF ANY CHANGES TO TBIS INFORMATION MMTHN 30 DAYS <br /> OF GE. <br /> November 2004 <br />