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E <br />Owner Statements of Designated Underground Storage 'rank (US'f) Operator <br />and Understanding of and Compliance with LIST Requirements <br />Facility Name: t'ark-woods Valcro <br />Facility Address: 1612 'W Hamner Lane <br />Slockl.on. (:A. 91209 <br />Fkwility Phone #: <br />T <br />Facility, ID #: <br />Treason for Submitting this Fonn (Cluck Om,) <br />LJ (:liange of Designated Operator <br />X t Jrdate Certificate Expiration Datc <br />Designated UST Operator(s) for this l+a NDL <br />PRIMAi V <br />Twig wted Openitor's Name: Karen R Arnniz <br />BUsnim Nome (0" (Ilfferc n1 from ahove): <br />Designated Operator's Phone 0: (209) 5184836 <br />Tt)tarnatiloralrl Code C11lIMA Certiticidiun 4: 5266643 -UC <br />Designated Operator's Name: <br />Business Name ('I,f clafferenr,from above'); <br />Designated Operator's Phone #: <br />international Code Council Certification #: <br />A.LfEKvArr: z (ypttorurt) <br />Designated Operators Name: <br />Rosiness Nftme (y (ijft:rimi frnm (above): <br />Designated Operator's Phone #: <br />International Code Council CLtiification 0: <br />Relation. to UST rawirty (Check cine:) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ gervicc Technician X (bird -Party <br />expiration Date: 07/16/09 <br />Relklt.inn to IIS"I' Vacility (l.heckOne) <br />❑ Owner ❑ Operator ❑ Employee <br />11 Service Trellnjc:ikui I. 1 Third-PUTty <br />Expiration Dutr•: <br />RelaUon to UST Facility (C"lwck Cru) <br />❑ Owncr ❑ Operator ❑ Employee <br />r-1 Sarvice Toubnician El Third -Party <br />Expiration Date.: <br />T certify that, for the facility indicated at the top of this page, the individual(s) listed atx)vc will <br />serve as Designated UST Operator(s). nx individual(s) will conduct and document monthly <br />facility inspections dnd annual J.acility employee training, in accordance with C:alifortiia Cade (A' <br />Regulations, title 2i, section 2715(c) - (f). <br />Furthermore, i understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): 24-Vli'd 2 <br />SIGNATURE OF TANK OWNER: C--- <br />DATE: 08/23/07 OWNER'S PHONE #: '7 �6 ?�" <br />NOTE: 1) SUBM1`1 TIJIS C.UMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) 11V JANUARY 1, 2005. THF LOCAL AGENCY LIST is AVA1LAiiT,F. <br />A'.t': wri�w.waterboard.5_ca.gnv/u.... COnt3cts/cuL)a ap„ s.lurrtl. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATT.ON WITHIN 30 DAYS <br />OF THE CHANCE. <br />Zoo/ Z00'd 9TTO# <br />November 2004 <br />tO:ZO L00Z'9Z'dHS <br />