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„ 12/27/2004 05:33 2098326070 MAINTENANCE PAGE 02/03 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: t t;,,bM '® A Facility ID t4: ;t- <br /> Facility Address: Reason for Submitting;this Pornr((:heck Ore) <br /> Change of Designated Operator <br /> Facility P e ,'�JW ❑ Update Certificate Expiration Date <br /> Designated UST Ogerator(s) for this ]Facility <br /> PRINIARY <br /> Designated Operator's Name: Relation to UST Facility((:heck Ono) <br /> Business Name(.(fdi.(ferentfrom above.)., Q Owner Q Operator V Rimployee <br /> Designated Operator's Phone#: u ❑ Servioc Technician ❑ Third-Party <br /> International Code Council Certification#: /Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differertr from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ 'Third-Party <br /> International Code Council Certification#: Expiration Datc: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: A Relation to UST Facility(Check One) <br /> Business Name(If dierent front above): ❑ Owner ❑ Operator ❑ Employee <br /> Drsignatcd Operator`zi PhVnC 9: ❑ Set vice Tedmicimi ❑ 'Mid-Pauly <br /> International Code Council Certification Expiration Datc: <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(e) -(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): <br /> SIGNATURE OF TANK OWNER: <br /> • DATE: r ( OWNER'S]PJJONIF#: (Q. 0 <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER. <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/ust/contacts/cgpaagys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />