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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />FacilityName: ' <' r `! Tj <br />Facility ID #: <br />Facility Address: N <br />QCi 1 1 L�(A S}CCV �vk C A QCJ 2- is <br />Reason for Submitting this Form (Check One) <br />1W Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 'ZQ9 S + _ ` (i O <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name:IEC 1 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator TM Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 93 Nq 0 <br />International Code Council Certification #:P AGI i <br />Expiration Date: YP4n�� 1 [• <br />J / <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 #: y -Al YIC4 <br />Expiration Date: , 1"1G <br />ALTERNATE 2 (Optional) J T j <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 />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 <br />SIGNA' <br />!17:11009 <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/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 />