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.fir✓ <br /> �r <br /> Owner Statements of Designated Underground Storage Tank(UST) <br /> eSnT)Operator <br /> and Understanding of and Compliance with UST Req <br /> ts <br /> Facility 1D#: j Q ' <br /> Facility Name: t ti Vt'f Reason for submitting this Form(Check One) <br /> Facility Address: <br /> V Change of Designated Operator <br /> p Update Certificate Expiration Date <br /> Facility Phone <br /> Desi Hated UST O erator s for this Bacilit <br /> f <br /> PRIMARY <br /> Designated Operator's Narnc: L. I �' �1 m m d Relation to UST Facility(Check One) <br /> )• AVS <br /> Business Name(Ifdifferent from above O d` -�e 5 D Owner ❑ or <br /> ❑ Employee <br /> Designated Operator's Phone#: 2o9) '� y ' Service Technician Q Zird-PartyInternational Code Council Certification#: �� y�� «" Expiration Date: j �Z , <br /> ALTERNATE 1(O tional h <br /> Designated Operator's Name: 7ZA tAE A. �yyl 5 Relation Co UST Facility(Check One) <br /> Business Name(Ifdifferentfromabove): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: [7�! `7 �/-Cr X Service Technician ❑ Third-Party <br /> International Code Council Certification#: (�yj`�7 �jk_C'J Expiration Date: g <br /> ALTERNATE 2 (©,phonal) <br /> Designated Operator's Name: mos LC 1 Relation to UST Facility(Check One) <br /> Business Name(If different from above): ,r _ ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: <br /> (5—9 Lr' 0e jai Service Technician C1 Third-Party <br /> International Code Council Certification#: 2 -a-- G 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 /> d <br /> S <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 employee training, in accordance with California Code of r <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(Please Print): T <br /> MM MAPINE IN <br /> SIGNATURE.OF TANK OWNER: �'i✓�u-x 1' �. /�v /" r J7c=/t' <br /> DATE: //`I U �¢j_ OWNER'S PHONE <br /> f <br /> November 2004 <br />