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Oct 12 10 01:51p Reliable Petrole 209-845-8953 p.2 <br /> Owner tatements of Designated Underground Storage Tank (UST) Operator <br /> d Understanding of and Compliance with UST Requirements <br /> [Paci',1"i't'tyrA <br /> acy 'arae: Facility ID#: <br /> d dress: 1 �' q tih[L✓l LQY1Ce Rcuson for Submitting this Farm(Check One) <br /> � CA` g7 X Change ol'DLsignatcd Operator <br /> hone P• — — ❑ Updaa:Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Dcsigna0.d Opera or's Name: cwlr'l- Relation to Usr Facility(Cheek One/ <br /> Business Name(/'drfJerenl from above). I )e- Owner ❑ Operator Cl Employee <br /> Designated Opera or's Phone <br /> _ PF_Servioe'J'echnician ❑ i'hird-Party <br /> IntemaGunal Cod Council Certification k:G151)S -U G Expiration Date: . �• <br /> ALTERNATE 1 O daaa! <br /> Designated Opera is Name: Relation to UST Facility(Check One) <br /> Business Name(( drfferentfrnm above): ❑ Owner ❑ Operator ❑ Empluyec <br /> Designated Opc is Phone 4: El ServiceTechnician ❑ Third-Party <br /> Imernational Code Council Certification k: Expiration Date: <br /> ALTERNATE 2Opfioxa!) <br /> Designated Operal is Name; ;Rclation to UST Facility(Check One) <br /> Business Name(if ifferentfrom ahove): ner ❑ Operator ❑ Employee <br /> Des'rgnnted Opera isPhoneN: ice Technician ❑ Third-Party <br /> International Code ouncil Certification R: ion Date: <br /> t certify that, 1,)r 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 inspect ons and annual facility employee training,in accordance with California Code of <br /> Regulations, Ole 23, section 2715(c) - (f). <br /> Furthermore, understand and am in compliance with the requirements (statutes, <br /> regulations, a d local ordinances)apppllicab o underground storage tanks. 26 . <br /> NAME OF TANI,OWNER(Please Print):( ilt/it GLS— J <br /> !LDA <br /> IGNATURE O TANK OWNER: 9 <br /> TE: "NER'S PH NE#: C - / 6 l—74/0 <br /> NOTE: ])SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br /> RESOURCES CC NTROL BOARD)BY JANUARY I,2005. THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT �_o;�}_;t u[yb, ) {S,Ca i)1'-L..=.Cl;gfICLsY q'2 i '111 <br /> 2) NOTIFY THE LOCAL.AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANG E. <br />