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04/11/2005 13:00 66136354F� DJA INSPECTION <br />r <br />RESTFINK MUM, <br />Dni � �ntround StAt�s Tank (uSi`) QP�rator <br />ownerStatements of <br />�+,mViiOnce with► <br />UST gats <br />and Understanding of and <br />aaillty N Mac: <br />�' <br />�+ 8nbtnitP�s� <br />acltit} Address: '' ��4 � /� <br />�}, C�FQfD=*NAW OP -Mor <br />C) i P&W. icetlm DOM <br />�aaitity ptuDw #= <br />- <br />t Briti[si'�si �iflr �6^ <br />79 <br />PR1 <br />�e9atiatt to UST Fflcility (L OCA ow) <br />Nr4mtl,d Uperatorr s Names C�k Im <br />tONPI+Rcd 7N G1 G <br />O Oantar 13 o Ftp)" <br />2taata (Ud((%M� above}: G��I <br />13 <br />T�u4�c ann 'hi -Patty <br />®PYWAbun <br />p 's phooe #: 91d 927-1557 <br />UIe: IV17106 <br />i Code 00-1tleQtl�osH� : 52SU299-T <br />AA I <br />Zoom MUST Facility (Check one) <br />vCpj's 3k G : rA St>•zd'ns <br />ItYG <br />0 EmP'ay- <br />b flvvl�t' C313tisi <br />rant � cbooei: CN�tI�'�1NPft�JS'�7N77�57Ym' <br />Nom(19Fdt, r -o <br />s�vuseTcchnidan 17 M7tix1-Patty <br />resign �s Phono 4i: 916.427 155T <br />DtAae: 121128106 <br />ltstet�ati Codd C0 i1 6: 5430492 M <br />ALLTERKAIM2 <br />dci UST Fat:oW (Chok Ong) <br />Dow"dQp r'e1 21o:.4I.V[N KUWRNp <br />p�TiNp►1�C.: <br />aysi�a N (fl • ` <br />❑ pvvn�r flptVor b <br />� gprvioo Ter�naician C] Third -Party <br />Operaweo Phone A: 916»421-1557 <br />gxpiry6on Dia; 12115AI6 <br />Emzrnationai Cade Council Ca[ti5 #: OM949-UC <br />cotBd et the top of Ns Me, individual(s) lid above Will <br />I c rrtif3► that, for. the facility ' will comduat and d mooddy <br />serve as UST s). " itiividuat(s).lvith Califoxnia Ccx 01•� and all &cfyty ell ooyee trauttng. m <br />ons, <br />We 23, section 271W) - M. <br />the requirements (etatutes, <br />]Furthermore, I >alnd® d and am in cnmpDMbje to rpu.d lad sto forks. <br />regul9t1ons, and l ord.iaane") tpP <br />jqhDa <br />OF TANK O <br />SloNATME OF TANK OWIClb <br />AiGENCY (NOT THE STATE WATM <br />Snr <br />,or Tgo COWLETED VOIRM To TOE LOCAL <br />RESOURCES COMMOL BoAW) By jANUAgy 1, 206S. TM LOCAL AGENCY LW IS AVA'LABLE <br />• .: .�_ ' Fl '° � � .c � Fir r` ,5.� ' . r,u. <br />�� .�.......; �.: y.. '3f... 30 1 <br />AYS <br />NoTgy TM <br />LOCAL AGE <br />Wovwober 2004 <br />