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Rug 12 09 04: 35p Chacko 2098387674 P. 1 <br /> t. -� • • Lti � _ ,N, <br /> a1 <br /> Owner Statements of Designated Underground Storage Tank (USi%RrWht <br /> and Understanding of and Compliance with UST Requirement$ <br /> LAI{/i_.(., 'OUNP( <br /> FacilityName: Facility ID#: °`f Ccr=aN7l�p , <br /> Facility Address: 1 W)a i i f n i Q St Reason for Submitting this Form(Check One) <br /> e--'rak 1 Ch. qsago Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Designated UST Ooerator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(Ifdfferentfromabove): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 5184836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> #International Cade Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opiloaal) - <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii ferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third•Parly <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 aunual 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 local ordinances)app 'cable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Prin . S <br /> SIGNATURE OF TANK OWNER: t /qq /� / <br /> DATE: l l OWNER'S PHONE#: �6 q 'O ( 1 Ol 6 q�3 <br /> NOTE: 1)SUBMIT TRIS 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: ucw.cvatcrboar is.ca n uti!,_ccnv tct ctipi aLN,.htnil. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />