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Mar 13 12 08:05p Reliable Petroleu A <br />-845-8953 p.3 <br />k <br />Owner Sitements-of Designated Underground Storage Tank (US TjAOperator <br />an d Understanding of and Compliance with UST Requir eq lvi�l ui,oui ,, <br />Facility Name: MUZ (, —T—S Facility ID #- <br />Facility Address: -4 /:; r q �} f 11 S t Reason for Submitting this Form (Check One) <br />S4' DG -fC d Q.sZ Q 6 ❑ Change of Designated Operator <br />Facility Phone #: 2 Q Q ,34' r. � X Update Certificate Exoiration Date <br />Designated UST Overator(s) for this Facility <br />PRIFMARV <br />Designated Operas is Name: Robert Barnhart <br />Relation to UST Facility (Check One) <br />O Owner ❑ Operator ❑ Employee <br />X Service Technician El Third -Party <br />Business Name (If ifrerent from above): Reliable Petroleum Semites Inc. <br />Designated Operatc "s Phone l€: 209-604-9336 <br />International Code 1 ' ouncil Certification #: 5252540 -UC <br />Expiration Datc.::.-. :.` . E-►� <br />AL -t EKsNATE I -ottad <br />Designated Opemt is Name: Guadalupe Sanchez Relation to UST Facility (Check One) <br />Business Name (If c �erent from above):Reliable Petroleum Services Inc. O Owner ❑ Operator ❑ Employee <br />Designated Opersto I's Phone it: 209-604-9363 X Service Technician 0 Third -Party <br />l <br />International Code ouncil Certification #: 5250451 -UC Expiration Date: 01-29-2013 <br />ALTERNATE 2 f alma.!) <br />Designated Operato �s Name: <br />Relation to UST Facility (Check One) <br />D Owner O Operator ©Gnployee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If erentfrom above): <br />Designated Operato Cs Phone #: <br />International Code ouncil Certification #: <br />Expiration Date: <br />I certify that, f 'r the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Design i ted UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspecti � s. and annual facility employee training, in accordance with California Code of <br />Regulations, tit k 23, section 2715(c) - (f). <br />Furthermore, understand and atm in compliance with the requirements (statutes, <br />regulations, am local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): <br />SIGNATURE Ol <br />DATE: <br />NOTE: I) SUBM <br />RESOURCES CI <br />AT: www.waterbs <br />2) NOTIFY THE <br />OF THE CHAN( <br />TANK OWNER: <br />OWNER'S PHONI? <br />THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />rROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />November 2004 <br />r <br />