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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Facility Address: 5 me®v! :5r "' U Reason for Submitting this Form(Check One) <br /> % 0 X Change of Designated Operator <br /> Facility Phone# ct) q3�2- -7ql( Update Certificate Expiration Date <br /> e <br /> Designated UST Operatoris <br /> j for this Facigly <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:(209) 518-4836 0 Service Technician X ThirdParty <br /> International Code Council Certification#:8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician El Third-Party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNA'T'E 2 (0pd9nd) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 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 OFT OWNER(Please P <br /> SIGNATURE OF TANK OWNER: (\� <br /> DATE:,-3/,-�O/ I OWNER'S PHONE#: 2-D 2 <br /> / r <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.waterboardsj_ca.gqv��ust;contacts'CL!RA 12VS.1-arni. <br /> --,— _4__ <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />