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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Facility ID#: Facility Address: $c r, g G Lje ra k e,e 1,cti a Reason for Submitting this Form(Check One) ❑ Change of Designated Operator Facility Phone#: X Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name:Alex Jabbari Relation to UST Facility(Check One) Business Name(Ifdierent from above):Norcal Petroleum Service Inc ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: 925-389-1262 X Service Technician ❑ Third-Party International Code Council Certification#:5243897-UC Expiration Date: 10/022012 ALTERNATE 1 'onal Designated Operator's Name: Relation to UST Facility(Check One) Business Name(Ifdii ferent from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: Cl Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore,I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicapbl-e( to underground storage tanks. NAME OF TANK OWNER(Please Print): /7CJ M/� t, pl USSRI N SIGNATURE OF TANK OWNER: DATE: 1-X49 11 OWNER'S PHONE M NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER •RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/cupa_agys.html.