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Jul 07 10 05:48p Reliable PetroleumA 209-845-8953 p.3 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 7�( j <br /> Facility IDFacility Address ; , �u`'l��"�� /�� Reason Por Submitting this Form(Check One) <br /> Change of Designated Operator <br /> Faei tyty Phone# <br /> ❑ Update Certificate Expiration Date <br /> Designated UST Oaerator(s) for this Facility <br /> PRIMARY <br /> 411VItemational <br /> "Counci, <br /> e.- <br /> Relation to UST Facility(Check One) <br /> om above). � <br /> 4 Owner ❑ Operator ❑ Employee <br /> e#: 20q\rc <br /> QtO Service Technician ❑ Third-Party <br /> ertification#: S 5 <br /> a-5 L[b-U C- Expiration Date: E 7 y3 Zo I , <br /> ALTERNATE 11r)-i;vna! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(!f different from above): <br /> 11 Owner ❑ Operator C1 Employee <br /> Designated Operator's Phone#: Q Service Technician C3 Third-Party <br /> International Code Council Certification#: <br /> Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: <br /> Relation to UST Facility(Check Una) <br /> Business Name(If different from above): <br /> Designated Operator's Phone#: ❑ Owner ❑ Operator ❑ Employee <br /> ❑ Service Technician 0 Third-Party <br /> International Code Council Certification#: <br /> Expiration Date: <br /> F, for the facility indicated at the tap of this page,the individual(s) listed above will <br /> ignated UST Operator(s). The individuals)will conduct and document monthlyections 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 10ca1 ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Pri <br /> SIGNATURE OF TANK OWNER: zl.. <br /> DATE: ``'C OWNER'S PHONE 9: 33 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAs,AGENCY <br /> RESOURCES CONTROL,BOARD)BY JANUARY (NOT THE STATjE WATER <br /> AT: 1,2405S.THE LOCAL AGENCY LIST AVAILABLE <br /> ,y,,; .;�ateri�oa;ds,ca., oy'llSt,C01][aCl'S�rL <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br />