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r 12/22/2004 02:47 2098326070 MAINTENANCE PAGE 02/03 <br /> Owner Statements of Designated Underground Storage Tank (LIST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: _' ,. Cbz, , Facility ID#: 'FhOw . <br /> Facility Address; t4�i,e, �), nc �:kt Reason for Submitting this'Fonn('Check Otte) <br /> C- 06,5-)(0 'k Change of Designated Operator <br /> Facility PAeAc#; aC) ° 3 -`$�aL) ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility((:heck One) <br /> Business Name(f different from above): 0 Owner rl Operator IP( F.mpinyc:n <br /> Designated Operator's Phone#: 'a„o,( - O Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE] O tienai <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator O Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date.- <br /> ALTERNATE <br /> ate:ALTERNATE 2 (Optional) <br /> Designated Operator's Name: „ Relation to UST Facility((:heck One) <br /> Business Name(1f different from above): O Owner ❑ Operator 0 Employee <br /> Dusiguatul opwt1ttu'a Mum;#. Q Scrvice Tcehnician O Third-Party <br /> International Code Council Certification#-:* Expiration Date: <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 /> R.egulatiotis, title 23, section 2715(c) - (f). <br /> Fnrthermnre, I understand and am in compliance with the requirements(statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> -•�+ l l <br /> NAME OF TANK OWNER(Picric Print): ca.! 1 C' <br /> SIGNATURE OF TANK OWNER- <br /> DATE: 1al .l� OWNER'S PHONE <br /> NOTE:1)SUBMIT TATS 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/contac,�,ts//cupx agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />