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Jana 04 07 04: 34p Rffnrda Test (209) 744-0116 p . 1 <br /> 01FB41200� 17:06 2099 372 STEPHENS-RTVPT DG PAGE 01 <br /> Uwncr Statements of Designated Undcrground Storage Tank (UST) Operator <br /> and Understandi og of and Compliance with.UST Requirements <br /> rr?y <br /> PacilitY ID <br /> F.aility,Addreu: Rauoo ibr%mmiadn=real Foam(Ch..*0,W <br /> 5'ffoa( 1 Ca VC,.._,t-r.,_ ''lo c ►�.. c�,.,,�o ottd est t>�.rd. <br /> .Fed Iity n=W X: f - - aUPdaft C4cifW0*Expimoon Date <br /> v <br /> DDWVamd Opwame's N*w: L 1 e N y M rn Q Rekbao sa Lase PacltLry to ck QMW) <br /> a a�zv.me(�dIG nV►+ nbvv�) IAf f a rd a. --re-s+ 00'.. a <br /> operator a ruaplv� <br /> D=iZ med Ogft wr's Mona* ze>q -L i 7- r Say"Technidnm 0 Tttin&P=W <br /> inccana6paJ Cade Cvuosail CQe(6a eioo r. .5'A y q 11 - U Dnm .12 o <br /> A[.TMNATL 1 faffldwamp <br /> 1}esiPQMd opw$Mx's Name: '-ZA c A. RAErd"W MT racltity(Mak 0—) <br /> &admen Name f�dl v+e.+rJFv+�.abor�). __ ❑ cA.ner 0 Opftvw a EvV4oyW <br /> DesiRoatee OperswPr's 1P6oae SM-11M Tccdmiam t7 T&M-P any <br /> 1abvA.tion.lCsiseCa�.ani�cmr:ricacar}Ae ea'3c'(i`�►�� _ ��� <br /> ALTIRNATR 2 n.lJ <br /> DrsiRanood()ptrrrrar's NatAc boy XCLEtk a to UST Fw-4p(Check Ono <br /> a wimm raga(!JdwiveHrjha+n°ha—)' o t)-- 4 op-mwr c zmyt*Y <br /> Dfivi aaicd opmows rhow r' 1j gCrv`a=Iftho CL4W r7 Thizd_" <br /> tamrnat(am'Coda Gana'Cesttfication Ak -7Fxylraaoa I)atr <br /> NOTE:T$$LOCAL AEGtal ATORX AGENCY MUST HE Na71P7ED Or ANY CHANGE$TO TMM <br /> ENFORs7rxA nON WrTOJW AD DAYS OF TBT CHANGF- <br /> 1 ccrrifyr that,for the facility buyicatod at the top of this page,the individual(s) listed above will <br /> save a9 Dcsiguted UST Clperator(s). The individu&J(s)will conduct and doc=cnt monthly <br /> facility irprc,naris and annual facility employee u inin&in at:c�a with California Cods of <br /> Regulations,title 23, section 2715(c)-(f), <br /> Fortharmara,Z underst"d and zia in compllaocr with the requiirements(atatut'.ea, <br /> regulations,and loci ordinances).applicable to undergrausd storage taaka, <br /> NAME OF TANK GWNnt(IPtea.e <br /> SICNATUU OF TA,NIK OWNER: <br /> awT2:_ 21-- owry rR-s rvtONz o- <br /> November 2004 <br />