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AUG 062009 <br /> Owner Statements of Designated Underground Storage Tank (U� <br /> and Understanding of and Compliance with UST RequireM"�--1-.,,? - <br /> Facility Name:-q--CKp_ i :26 Facility ID#-. <br /> Facility Address, 57q W r <br /> -At) I/k,0- Reason for Submitting this Form(Cheek One) <br /> - GL <br /> TO LkQ Change of Designated Operator <br /> Facility Phonc# X Update Certificate Fxpiration Date <br /> Designated UST Orperator(s)for the Facility <br /> PRJMAJRY <br /> Designated Operator's Name.Karen R Arnaiz j Relation to UST Facility(Check One) <br /> Business Name(If different front above): El Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:(209) 519-4936 M Service T=.bni6,,n X Third.4>2ny <br /> International Code Council Certification 4 8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Raqine.izq Name(ydifferentfrona above), 0 Owner 0 Operator 0 ErriployQc <br /> Designated Operator's Phone Lj Service Technician 0 Third-Party <br /> 41riternational Code Council Certification# Expiration hate: <br /> ALTERNAT9 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Chock Ong) <br /> Business Name(If differentfrom above): 11 Owner 0 Operator 0 Employee <br /> Devigriated Operator's Phone ii: 0 Service Tcchnicikm El 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 2 715(c) - (f). <br /> Furthermore, I understand and am in compliaoce with the requirements (statutes, <br /> regulations, and local ordinances)applicable to underground storage tanks. <br /> F TANK OWNER(Please Print): <br /> OF TANK OWNER: <br /> DATE- & S PHONE 0: <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-waterboard-s.ca.2o\,/usuconiacts/cul)a a2vs.hirni, <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANCES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> Novcmber 2004 <br /> Z0/T0 39Vd GOOJ SV9 3NO V 9L9z668G0z SZ :00 60OZ/90/80 <br />