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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: &I'—'k �S4 .4 <br />Facility ID #: <br />Facility Address: / > 5�3 ✓ca &) <br />✓L,9S C19 7�5 3-? <br />Reason for Submitting this Form (Check One) <br />e Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 2 69 - !K3 6-- S'2 <br />Designated UST Ouerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: S E5z At'LIC/Ifial Cc - ie <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Third -Party <br />Business Name (Ifdifferentfrom above): WjgZ�4A/ ,/ �;t,2in/ Tvc< <br />Designated Operator's Phone #: q/ — �3,72 — j81�� <br />International Code Council Certification #: 5e -t 191t-?c1i,; cf Ct`R fS, <br />Expiration Date: 0c/64k,:z /Z, 2 cio 6 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, 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� /� <br />OR OWNER'S AGENT (Please Print): �i%<�� ���� ��� ��';`►� w' <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: 44 c, 27 z od ` OWNER'S PHONE #: �'�C�" '7ty5✓- Z �S <br />September 2004 <br />