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FFec 31 04 09:26a Alex 92L.551-7892 p.2 <br />Owner Statements of Designated Underground Storage Tack (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Naane: PdLeok tLP" Facility ID #: <br />Facility Address r �® Reason for Submitting this Form (Check One) <br />I b i a w. tiQ W1:V1 ��''�-'i"Q+'l `51 iiC: /1 �{} C] �h�nbe of Desigatated Opet ttor <br />Facility Phone #: ZQ Update Certificate Expiration Date <br />Desimated UST Ogerator(s) for this FACIA <br />PRIMARY <br />Designated Operator's Name: f,� f L+, �• Relation to UST Facility (Check Une) <br />Busincss N== (If dgeretrt from above): 8 Sur=e L3 Operator Jk Employee <br />Designated Operator's Phone # y ❑ervice Technician Lal 7 bird -Party <br />Internadonal Code Council Certification #: _ Expiration tic:1p '1 — d <br />ALTERNATE 1 O 'ona! <br />Relationto USP Facility (Check One) <br />Designated Operator's Name: <br />❑ Owner ❑ Operatrm E3 Employee <br />r3 Service Technician C3 Third -Party <br />Business Name (Ifdifferent from above): <br />Designated Operator's Phone #' <br />Int muittional Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 O iorrat <br />Relation to UST Facility (Check One) <br />Designated Operator's Name: <br />❑ O%vaer ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third -Party <br />Business Name (1f dir ferent from above): <br />Designated Operator's Phone #: <br />International Code Council C:ertiflcalion #: <br />Expiration Date: <br />on •r.n •ruaC <br />NOTE: THE LOCAL REGULATORY A4-rX NUY muar IIom r®a r a arar.as v. �•_ ' -'-~ – - <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I Gratify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST ®perator(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) <br />Furthermore, I understand and am in compliance with tete requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER I4 1 j� r <br />OR OWNER'S AGENT (Please Print): t V N'\L41F CS J � l <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />September 2004 <br />