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Mar 19 10 09:51a Reliable PetroleumA 209-845-8953 p.2 4 i Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Facility Addresslmoo - ity ID N: �.7•SS S `�• 9 Reason for Submitting this Form(CheeA(hie) �$ an W Che of Desi Fneility Phone!!- .4.1) Z.A fi �naled Operator _ � ❑ Update Certificate Expiration Datc- Designated UST ODeratorfcl for this Facility PRIMARY Designated Operator's Name: O It'll,. Ql.� U Relation to UST Facility(heck One) �1 Business A'amc(Ifdi�ererstj?um above).• . Designated Operator's Phone N:� p S� t V• Owner 11 Operator ❑ Employee ff�— f 3 3 Service Technician ❑ Third-Party International Code Council Certification u:STSL S 6xpirazionDate: JL 23 t0(/ ALTERNATE 1 (Optional) Designated Operator's Name; Relation to UST Facility(hrerk One) Business Name(IfdiJferent from above): DesigmttedOpcaa[or'sPhone#: ❑ Owner ❑ Operator ❑ Employee 13Service Technician ElThird-Party international CadeCuuncil Cdrtitication k: Expiration Daze: ALTERNATE 2 (Optiand) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(Lf different from above,): Designated O ❑ Owner ❑ Operator 1:1 Employee 8 Operator's Phone#: ❑ Service Technician ❑ Third-Party .;,.z. International Code Council Certification 9: kxpimtion Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c)-(f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances)applicable to underground storage tanks, 154 NAME OF TANK OWNER(Please Priot): (l�Nv mr<I/M—�2L'rs LLC �/Ifc II SIGNATURE OF TANK OWNER: P DATE: 10 01NER'S NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY I,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:_ww w,ltu_I?na}_cJti Ft.eS fru}i gm�cts c'g,a aevs.hunl. 2);NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANCE.