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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and I inderstanding of and Compliance with UST Requirements <br /> Facility ID fl: <br /> Feces;1��Name. Reason for Suhnitting this Form(Check Orr) <br /> ,, •` ��� � �,� �.� �-_ L.� ❑ Change ofDcsignazedOpetator <br /> Fatiiip'1'txvac a: - ..��j �' ❑ Update Certificate Expiration Doe <br /> Desienated UST Oneratortsl for this Facility <br /> PRIMARY <br /> DeslQnsted Operator's Name: V Relation to UST Facility(Check One) <br /> ! �- — <br /> .-� -� ❑ Owner ❑ Operator 11 Employee <br /> Business Name(lfdrfferent f <br /> Designated Ope <br /> tator's PhonService Technician ❑ T tird-P-- <br /> Intertwtiona!Code Council Certification#: 2 - ' Expiration Date: 1 <br /> ALTERNATE 1 Iona! <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name: <br /> Business Name(/fdifferentfrom above): _ ❑ .Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#.{2. Z Service Technician ❑ Third-Party <br /> International Code Council Certification#: �j1 — Expirauion tate: <br /> ALTERNATE 2 (Optional) <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name: <br /> Business Name(lf different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Parry <br /> Inernational Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 <br /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore, I understand and am in compliance with the requirements <br /> regulations, and local ordinances) applicable to underground storage tan <br /> NAME OF TANK OWNER t <br /> (- q <br /> OR OWNER'S AGENT(Please Print): <br /> ,f*'GNATURE OF TANK <br /> ,,WNEROROWNER'S AGENT: < tj <br /> LATE: �j f I�OWNER'S PHONE #: _____,_ <br />