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0 0 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: �/ FacDlity ID #: <br />Facility Address: Zv ef/,I7 Z--1/I°Reason for Submitting this Form (Check One) <br />5'Toc4eTorl/ e.4 9'.ca-fo6 ❑ Change of Designated Operator <br />Facility Phone #: %— �/ ❑ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />Designated Operator's Name: A /6X <br />Business Name (Ifdierent from above): <br />Designated Operator's Phone #: dll <br />In;;m nal Code Council Certification #: <br />Relation to UST Facility (Check One) <br />f7 Owner ❑ Operator CJ Employee <br />❑ Service Technician W Third -Party <br />Expiration Date: Io_ <br />AUI e:KINA ICI nor <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (ifdierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />Designated Operator's Name: <br />Business Name (IfdIerentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ ServiceTechnician ❑ Third -Party <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NV l ll'IEII wr r lx III-" <br />... • •-- <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 emplgyee 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 storage tanks. <br />NAME OF TANK OWNER <br />OR OWNER'S AGENT (Please Print):;S,t t R t o RE p 31 niceN 5*21 <br />SIGNATURE OF TANK lJ � el <br />OWNER OR OWNER'S AGENT: <br />DATE:/ �S G y OWNER'S PHONE #: <br />September 2004 <br />