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c <br /> Owner Statements of Designated Underground Storage T (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: (:e9!4 A/'Tk y MALT 76. Facility ID 3 ® f <br /> Fi/'fittyy d essS a�/SM fl N —FIL4 C y C4 Reason for Submitting this Form(Check One) <br /> 5S'376 • lV Change of Designated Operator <br /> Facility Phone#: QCT 1 — 3-a- ❑ Update Certificate Expiration Date <br /> esig ated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:John Courant Relation to UST Facility(Check One) <br /> Business Narne(If different from above):California USTServices a Owner ❑ Operator 11 Employee <br /> Designated Operator's Phone#:(925)595-8230 X Service Technician 0 Third-Party <br /> International Code Council Certification 0:5242457-UC Expiration Date: November 3,2008 <br /> ALTERNATE l Pions! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different frorn above): ❑ Owner ❑ Operator Ci 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 different from above): C Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: D Service Technician ❑ 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 /> 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(Please Print): 'r��sr <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 2— !S�—O '? ' OWNER'S PHONE#: 2 0 9. F3 a . 9"Z— <br /> NOTE- <br /> "z.._NOTE: I)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY I,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www waterboards ca.gov,,usticontacts/cupa agvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> Z-d 6L969C960Z6 }uemoo uyor d-V-V:�O LO 9L Gel <br />