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DEC 3 0 200 <br />Owner Statements of Designated Underground Storage �-oo- . • <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />FacilityID #:VAO(0392,la <br />Facility Address: <br />IC110 ccoi; pockAi-GAC.i bVi CA qszllsR <br />Reason for Submitting this Form (Check One) <br />Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 20 '(4 i crjo <br />•rs s-rr T+: <br />Designated Operator's Name: t4ichaeA Athqq'Smilln <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 #: L . 2 <br />International Code Council Certification #: N 1 - <br />Expiration Date: v% ® A <br />® I TTP RN ®TF 1 //b.s8n. h <br />Designated Operator's Name: !t, <br />Relation to UST Facility (Check One) <br />Owner C5 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: W <br />ALTERNATE 2 (Ontionah <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 />turtnermore, <br />regulations, and local ordinances) applicable erground storage tanks. <br />1141,WE OF TANK OWNER (Please rin <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />SOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca,aov/ust/contacts/cuDa aL-vs.html. <br />1 / 1 1 / '' 1 11• <br />OF THE CHANGE. <br />November 2004 <br />