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Dec 29 04 05:03p Alex 0 9651-7892 p.8 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: — <br />y �y <br />Facility to #: <br />Facility Address: J/101fr ZO �'�j//�� j <br />sxoce%a7xf� <br />�j�i/Jy/ <br />Reason for Submitting this Form (Check ow) <br />❑ Change of Designated Operator <br />❑ Update Certifrwto Expirffiion Nate <br />Facility Phone #: O %_ _ y <br />Designated UST Ooerator(s) for this Facility <br />'4.1._1111 7 <br />Designated Operator's Namc: 916 Relation to UST Facility (Check Om) <br />Business Name(Ifdid-er&afrom above):Owner ❑ Operator 9 Employee <br />Designated Operator's Phone #: qZ ❑ ServiceTechnician A''rhird-Party <br />International Code Council Certification #: Expiration Datc: <br />ALI kJNAI'b 1 (Vionar <br />Designated Operator's Names <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ ServiceTechnician ❑ Third -Perri <br />Business Name (Ifdifferenrfmm above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE2 f mimun <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Parry <br />Business Name(Ifd„Qerenrfrom above): <br />Designated Operator's Phone #: <br />International Cade Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I certify that, for the facility indicated at the top of this page, the indivitlual(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 2915(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): SSU Q 1 lid Q i I�t�R N STa IJZ� / <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: <br />OWNER'S PHONE <br />September 2004 <br />