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05/08/2008 08:50 FAX SJhH LpjUUz <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance With UST Requirements <br /> Facility m r _ <br /> FeciLry NB1°e' Reason for Sobno"h' this Font(Check One) <br /> Aaere,e: �4�p �Jesi rart�l��e d ' <br /> .( � gg3 <br /> Change, of Dcatgnrted operator <br /> Feoillty Phone 0: . <br /> Deeisa>•�T entpr(al for thla <br /> rR1t«IwRv — Rah ion m usi F.cuay(Cheaore) <br /> 1)e�gkmed Opengef'e Name: David A.Winkler <br /> Baginaae xamo(lfmBermni from abawo. off-,4 Teat Service Technician <br /> nest anaoed t�eors rye, _209 744 0112 <br /> rnlerartlanal cave couadir cdnis�.iioa x: _ 5263373-UC sxpi,.noo Here: 3/3/08 <br /> ALTERNATE I.fOsdeew) <br /> Zone A.NimmO Relation to USTpwytiry(check oar) <br /> UniEn.tdd Oper�edrY Nmnc: <br /> Basmcaa Name(U '^ehaea&doer): Afford&-Test <br /> 209 744-0112 Service Technician <br /> oetdpued Operator's Phone 0: ... <br /> International Cede Caand l CotNacation e: 5263322-UC i�an Date: 2 /111; <br /> ALTRBNATE 2 /Nm ►) _ -- <br /> D"igemod Openeer's None: Lyle.D.NimomRewou to UST Faciaty(Cheek ane) <br /> gusiame Name(rfd�,Qerrwr from a6ave): _ _Afforda-Tent Service Technician <br /> oesttmed oparsta a fin,e; <br /> 20744-0112 <br /> Intetaetimal code coma ccrocaaan s: ...,. 5249115-UC Expiration Date: 7/1/09 _ <br /> I certify that,for the facility indicated at the top of this page, the individual(s)listed above will <br /> serve as Designated LIST Operator(s). The individual(")will conduct and document monthly <br /> facility inspections and annual facility employee training,in accordance:with California Code of <br /> Regulations,title 23,section 2715(c) -(f). <br /> Furthermore,I maderstand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage tank&. <br /> NAME OF TANK OWNER(Please Print): l_J .A'tV14 `- ' <br /> SIGNATURE OF TANK OWNER: <br /> DATE:, QS.._. .�OWNER'S PHONE.N: <br /> NOTE:1)SVDMrr TRIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES COrr1'RO4 BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: wjse arch, aeon/asst/goatacts/tuba_.�F.html. <br /> 2)NU2TFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WrrEHN 30 DAYS <br /> OF THA CHANGE. <br /> November 2004 <br /> Z0 39dd Z a39I1 TBETEZ8 91:50 000E/Lt/T0 <br />