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KAREN ARNAIZ `N:0, 06334 <br /> "t ?,. PSP 4 04/e7 <br /> Owner Statements of Designated Unde <br /> rgrollyad Storage <br /> 10d U10611standing of and Compliance MVV US:[ )(e k(UST) <br /> nOPerator <br /> MAM; <br /> AacllhylD#:�� ReasonZ <br /> bmiu(ngArls po, <br /> C <br /> 0)-D, Operatoc <br /> X U �ificateExpirationbafi <br /> Designate I T Oaerato s1 for tWS F`acja <br /> PRIMARY <br /> 13"1 <br /> 8 <br /> nated operatoes Nanta wren ld Arosiz <br /> Buaiu, Name(rfd' erenf Ro UST pawlelaHOn t <br /> from above); ID'(Chaok One) <br /> Designated Operator's Phone#: 209)518-4836 ❑ Owaer 13Operabr ❑ kl,,, e <br /> lntematlonal code Couaail Celcation#.8032295-UC Q Service Technicivn x rLird-Party <br /> ALTERNATEI o natal .oxpi.�atteaDate:06/Z�./20�3 <br /> Oeylgoated Operator s Name: <br /> Buslneas Name(ffd(gerenifrorn above); Relation to UST Facility(Check one) <br /> Designated Opetatof s Phone#: Q Oaner ❑ Opemor ❑ g <br /> r.pfaV e <br /> #International Code CouncilCcrtifieation A: 13 Service T°j1114� ❑ Third <br /> ALTERNAT&2 (pp&,o N-Plratlon Date: <br /> Des(gnaW Operator'sNmne' <br /> B0slnoasNam e dt event Relation to UST Facility(Check One) <br /> ( .� f+'om above)- <br /> Desiguatedoperator's Phone N: ❑ Owner n Operator ❑ Employee <br /> International Code Council Certification# ❑ Service Techs cimr, b T6 rd pay <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 individuals)will conduct and document MOWWy <br /> facility inspections and annual facility employee training,in accordance with California CO <br /> Regulations, title 23, section 2715(c)- (f), de o <br /> Furtbermore,Z understand and sun in eomphance With the requirements(stahtte5, <br /> regulations, and local ordinances) Applicable to underground storage tanks, <br /> NAME OF TANK OWNER(Please prunt)° G <br /> srGrg zultE o.F TANK ONYNER: <br /> DATE: OWNER'S PHONE 4k �� I <br /> NOTE: r)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WAFER . <br /> RESOURCES CONTROL BOARD)By JANUARY I,2005.THE LOCAL AGENCY LIST 1S AVAILABLE <br /> AT: w"'waterboMd ra 14Y/,s/ Ontee a,c a a s h <br /> ��.BY�vs�ru• <br /> Z)NOTIFY THE LOCAL AGENCY OF ANY CHANGES'1'O'1'HIS INFORMrAfloN WlTNrN 30 DAYS <br /> OF THE CHANGE. <br /> Noveptber 2004 <br />