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Feb 28 10 01:16p Arco AMPM 2098308293 p.1 f ynl 1`1e j �- . :�. Y � n stiff�. MAP o l 2010 C:01tvTy Owner Statements of Designated Underground Storage Tank (UST:) Operator and Understanding of and Compliance with US`i'' Requirements Feciliny Name: 02 Facility IDR: Pacilify address: Toe- 10,4m)00 Pd r-K J0.a� Rzason for Submitting Ehis Furm(C iltdck One) f ra 0- C A 95 . C3Chakge of Designated Operator Facility Phone : q� O -'7-7 Ilk Update Certificate Expiration Date Designated LIST Operators)for this Facility PRIMARY Designated Operator's Name: �.� 00r r1 Relation to UST Facility(Check One) Business Name QI'different from ab(,ve): P. rAld.. Owner ❑ Op:rator ❑ Employee Designated Operator's Phone 4: Q q_ Service Technician C3 Third-Part; International Code Council Certification lf:SZ-15 257 Lj 0–LLC Expiration Date: j2–Z3–7?pl1 ALTERNATE I Qtionai Designated Operator's Name: Relation to LIST Facilit=y(Cheek Otte) ij Business Name(l'dTerenrft-omabove): ; O Owner ❑ Operator C Employee Designated Operator's Phone z; C Service Te,:hnician ❑ Third-Party International Code Council Certification 1 .Expiration— Date—ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check Om) Business Name(!f different froth ubnve): ❑ Owner ❑ Operator ❑ Employee Dcsigmaed Opemlor's Phone#: ❑ Service Technician Q Third-Parte International Code Council Certification#: Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance v ith California Code of Regulations,title 23, section 2715(c)- (fj. Furthermore,I understand .and am in compliance with the requirements (statutes, f regulations, and local ordinances) applicable to underground storage tanks. 1i NAME OF TANK OWNER(Please Print): • SIGNATLtRE OF TANK OWNER: i DATE: t;2 — 'J D OWNER'S PHONE#: - 5-71-40 i ;NOTE: I)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY I,2005.THE LOCAL AGENCY LIST IS AVAILABLE 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OFTHE CHANGE.