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FROM :EMILS FAX NO. :2098387674 Dec. 16 2005 02:55PM P1 <br /> �4tn, -/o .- '�(4 h�i�t'lsoh <br /> l� <br /> Owner Statements of Designated Underground Storage Tank(UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name; 6 Q Facility ID#: 00en D <br /> Facility Address/�6's- C�L J G lo 19 6 �. Reawn for Submitting this Form(Check One) <br /> �3 Q'0 X Change of Designated Operator <br /> Facility Phone#: 0 Update Certificate Expiration Date <br /> Designated UST ODeratorfs) for this Facility <br /> PRIMARY <br /> neai®hated Operator's Nae.- Karen R Abbott Relation to UST Facility(Check One) <br /> Bus nese Name(If diAasent from above): <br /> Desi ,yw pt, meY s Phone#:(209)518_4836 ❑ Owne, Q opmator ❑ Employee <br /> International Code Co 0 ServiceTochnician X Third-party <br /> until Certification#:5266643-UC <br /> ALTERNATE 1 - <br /> Expiration Date.10/12/07 <br /> Designated Operator's Name: <br /> Business Name 1'di Relation to UST Facility(Check One) <br /> (I fferenlfromabnve): <br /> Designated Operator's Phone#: ❑ Owner ❑ Operator in Employee <br /> Intematiowl Code Council Certification#: ❑ Fico1-echnician q Third•Party <br /> ALTERNATE 2 (OplianaExpiration Date: <br /> y <br /> DesigAated Operator's Name: <br /> Relation to UST Facility(Check One) <br /> Itusinea5 Name(Ifd�eren!from abrrve): <br /> Designated 0 Owner ❑ Operator ❑ Employee <br /> gn l Code Council c ❑ Service Technicim 4 'Third-parry <br /> International(:ode Council Certification#: <br /> 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 2715(c)- (f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground <br /> �sttorrangetanks. <br /> NAME OF TANK OWNER(please Print/): <br /> SIGNATURE OF TANK OWNER: <br /> DATE:_L��..�Os OWNER'S PHONE#: <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2003.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.W.Iterboards,c;a.gov/nst/contacts/cupo aRys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />