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4 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: s4c, Facility ID#: <br /> Facility Address: /1 l S` Reason for Submitting this Form(Check One) <br /> 14,8,0 4 1,�-C R 9K Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: SAF A#,g0A"4 e1 Relation to UST Facility(Check One) <br /> Business Name Qfdifferentftom above): i?L7tDn1 i/ ZVC< ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: c�f 6 —,3,72 ❑ Service Technician Third-Party <br /> International Code Council Certification#: &k It'l C Aq C/ c R Expiration Date: (jC��j�� /�� 2�,p 6 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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`<k'' /)/fir►/� �t�'it w' 1C ��°� ��' k� �'�G' <br /> SIGNATURE OF TANK <br /> OWNER OR OWNERS AGENT: <br /> DATE: /Jk c, 2 7, Z f<a`7{ OWNER'S PHONE#: <br /> September 2004 <br />