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AUG/07%2009/FRI 07: 05 AM FOOD FOR LESS WH. FAX No, 12098580108 P, 004 <br /> 08/06/2B09 20:55 2098679 KAREN ARNAIZ • PAGE 04/07 <br /> Owner Statements of Designated Underground Storage Tack(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Feci ,Name: Facll4IDp: <br /> Fadlity.A.ddre s: '7 �f(.eY'-k Reason for Submitting this Point(Check One) <br /> P_ r Change aPesignsxd Operator <br /> Facility Phone# X Updeto certifreote Expiration Date <br /> Designated UST OPerator(s) for this F'acI& <br /> PRIMARY <br /> bes>„rreated Operator"s Na�ttte:]�AreA��71aLZ Relation to UST Facility(Check One) <br /> Rusines3Namewdrlfare"tfrom above)= ❑ Owner ❑ Operuor ❑ Employee <br /> Designated Opuater s Phone#: 0951.84836 ❑ Serviec Technicim X Thir&Fany <br /> Intern,atiotral rode Couecil Certltication#:8032295-UC Txpiration Date:06/20/2011 _ <br /> ALTRRNATE 1 riono[ ._ <br /> Designated Operator's Name: Relation to UST Facility(Check Dns) <br /> auliDez Name(f{dtt%renrfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Fbone#: ❑ Servioc Tbchuician ❑ Thud-Party <br /> #International Code Cotmeil CettibcatiOn*: P.xpttahon Date: <br /> ALT ATI.9 2 (0pd0a49 <br /> Designated Operator's Name: - Relation w UST Facility(Check One) <br /> 13usiuess N=c(ffd($erew froth above): Q Owner 0 Operator ❑ Employee <br /> `.i DcsignaredOperator'sPhone9: ❑ SelcvlcaTechnfcStw ❑ Tltud•Party <br /> ltrtemational Code Council Cer4cAfiw#: Exptrauon Dau <br /> I certify dean,for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Desipated UST Operator(s). The individual(s)will conduct and docum at monthly <br /> facility inspections and annual facility employee izainulg,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)appllcnble to underground storage tanks. <br /> NAME OF TANK OWNER(PleaaeFrio t): e 1F ��✓�aN� �ater Alrgu-� <br /> SIGNATURE OF TANK OWNER: <br /> DATE: O I OWNER'S PHONE#* oma( STSG O/� <br /> NOTE;1)SUBMrr THIS COMPLETED FORMA TOTHE LOCAL AG19NCY U40T TIS STATE WATER <br /> REBOUBCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST TS AVAILABLE <br /> AT: www waterboards cz�ov'usyicentectsicuva o c�httnl• <br /> 2)NOTWV TM LOCAL AGENCY OF ANY CHANGES To T'H1B INFORMATION WIT1I11s 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />