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0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: /j Facilityl])#: yiy000 Vl <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> MO —3 3 7 jk Change of Designated Operator <br /> Facility Phone#: Zoos 2 _ 7po ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Mt)(E �74 j p3 q/?( Relation to UST Facility(Check One) <br /> Business Name(ydfferentfromabove): Of/3DIo yalle pelrolat)0 ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Q 2,5 '3 g q t 2-117— ❑ Service Technician A Third-Party <br /> International Code Council Certification#:9'2t4 3$'l'7— U C Expiration Date: I O - I - 6 <br /> ALTERNATE ftfionaQ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (0p9ioea0 <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dfferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <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 /> 1 Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations, and !Heal ordinances) app!ieable to underground storage tanks. <br /> f <br /> NAME OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print):,�J/,�.�t/ S�i:i/G t/ q)'R1 <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: _ alP1122 S IWIS& <br /> DATE: _ v/_/5l.-o OWNER'S PHONE#: 10 q —��;2 <br /> Screibranf <br /> $rt n !?rx—10 P✓d Q '4 S'3 September 2004 <br />