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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: <br /> Facility ID#: <br /> Facility Address: 1 tt L( r•O Reason for Submitting this Form(Check One) <br /> FacilityPhone#: 7 cc ❑ Change of Designated Operator <br /> X Update Certificate Expiration Date <br /> Designated UST Ooerator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Alex Jabbari Relation to UST Facility(Check One) <br /> Business Name(/f different from above):Aorcal Petroleum Service Inc ❑ Owner ❑ Opcmt ❑ Employee <br /> Designated Operator's Phone#: 925-389-1262 X Service Technician ❑ Third-Party <br /> International Code Council Certification#:5243897-UC Expiration Dale: 10/0271012 <br /> ALTERNATE 1 lianal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(/fdii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(7fdii Brent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> Ffacilitytinspections <br /> for the facility indicated at the top of this page, the individual(s)listed above will <br /> ignated UST Operator(s). The individual(s)will conduct and document monthly <br /> and annual facility employee training, in accordance with California Code of <br /> 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 Prion): A i rl' /✓� l i i C' 7hn%i:.1\%� f�il1G _l%M <br /> SIGNATURE OF TANK OWNER: % �r .4y s ,C ,,r .tJ �l- /'�i, ie a <br /> DATE: 1. t% OWNER'S PHONE#: fIC cI s� :SrOf'j— <i jis t/ _ je .9j <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: �; ;�c.i,a�erbnanicca.::�� lsicnntaciscuna necs.Mm;. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />