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06/20/2011 11:08 2098337676 A ONE GAS FOODPAGE 01/01 <br /> Tom ,' M'.']'" <br /> Owner Statements of Designated Underground Storage Tank (LIST) Optmuwr 'V 9 0 ?v <br /> and Understanding of and Compliance with UST Requirements11 <br /> Facility Name: A -ow Z Cry .r.t A Fact7ity ID#: - <br /> Facility Address: Reason for Submittingthis Form Check One „ <br /> G <br /> f q G Cbwge of Designated Operatm <br /> Facility Phone#: l., ❑ Updato Ccrtificate Expaution Datc <br /> Designated UST Ot.yrator(s)_foir_this Facility <br /> PRIMARY <br /> Designated Operator's Name: <br /> Relation to UST Facility(Check One) <br /> $„c�ney2a l\An1C(3fd j�er.•.+r f nn, rhmw) S”" T Q Ovoner Q Oper=or :n Famployea <br /> Desjgnated Operator's Phonc#: —9 X Savicc Tochnician ❑ Third-Party <br /> International Code Council Certification#' �(�,(.�Z� _ �/� F-*rntinn nate: —7 <br /> ALTERNATE 1 vR& <br /> Desigaatrd Operator's Name: RCMcm to UST Facility(Check One) <br /> Business Name(If dYVP--W from above). p Owner ❑ Operator ❑ Employee <br /> Designated Clpe-rator'e Ph me 97 ❑ Service Tedtnician 17 Third-Party <br /> latemaboW Code Council Certification#: Fxpirmion Date' <br /> .ALTERNATE 2 (Opdand) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> BusinrssName(ydiiffPrvretfinm nhnVe)' p Owner ❑ Operator ❑ Employee <br /> Designated Operalor's Phone#: [i Service Technician 11 Third-Party <br /> Intemadonal Code Council Certification#: Expiration Datr. <br /> I certify that,for the fac ility indicated at the toll 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,11 title 23,section 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> ircgulatiious, and local ordinances) applicable to undeWound storage taiuks. <br /> NAME OF TANK OWNER(Please Print). A-o <br /> SIGNATURE OF TANK OWNER: W <br /> DATE: (cab I / OWNER'S PHONE#: � "� C <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,20Q5_T1IE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: w-,v\v.watcrboards.ca—igv!usi%contacts/aim a �) htnt. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO TTS MOl.2MATION WITHIN 30 DAYS <br /> OF THE CHANGE_ <br /> November 2004 <br />