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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: Ci <br />C!/J t)S L <br />Facility ID#: <br />Facility Address: <br />S7MP A—Gi k Zb <br />Reason for Submitting this Form (check one) <br />El Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facili Phone #: O? — �7- 49r <br />Designated UST Operator(s) for this Facility <br />Primary <br />Desi Hated Operator's name: Dan Mcllrath <br />Relation to UST Facility (check one) <br />❑Owner ❑Operator ❑Employee <br />❑ Service Technician ❑ Third -party <br />Business Name: Valley Underground Tank Monitoring <br />Designated Operator's Phone #: 20g 476-1805 <br />International Code Council Certification #:xx4141012575 lExpiration Date: 11/13/2006 <br />Alternate 1 <br />Designated Operator's name: <br />I Relation to UST Facility (check one) <br />jElOwner ❑Operator ❑Employee <br />10 Service Technician ❑ Third -party <br />Business Name: <br />Designated Operator's Phone #: <br />International Code Council Certification #: I Expiration Date: <br />Alternate 2 <br />Designated Operator's name: <br />Relation to UST Facility (check one) <br />❑Owner ❑Operator ❑Employee <br />❑ Service Technician ❑ Third -party <br />Business Name: <br />Designated Operator's Phone #: <br />International Code Council Certification #: lExpiration Date: <br />Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED uF ANY Ctiw_Nuws I u <br />THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. d p LL� �& C-, � a L- v <br />DEC 2 4 2004 <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed abov� <br />Designatd UST Operator(s). The individual(s) will conduct and document monthly Facilit} <br />and annual facility employee training, in accordance with California Code of Regulations, <br />title 23, section 2715 (C) - (F). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br />and local ordinances) applicable to underground storage tanks. <br />Name of Tank Owner <br />or Owner's Agent (Please <br />Signature of Tank <br />Owner or Owner's A ent: <br />Date: Z, f �) <br />V <br />Owner's Phone #: Z� fj dt ? Z ?Z y <br />