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0 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> I;tcility Name: /,n/ �L.1� u-__ Facility ID#: - <br /> Pacility Address: <br /> Reason for Submitting this Form!('heck Ones <br /> ` ;}-�:-"� ,$C Change ol'Dexignated Operator <br /> Facility Phone li: �L.G n ,_ <br /> --. —. _-,_,� ��—�_�<,1` ❑ Update Ccgiticatc I xpirati..n Date <br /> Designated UST Operator(s) for this Facilites <br /> PRIMARY _ <br /> -- <br /> Designated Operator's N;tmc ------ <br /> -.1 I t\I Relation totIST Facilitv (('herk Ont) <br /> LBusiness Name(lf'dilf,reni(runt above): Pliable <br /> -��1tUleU r e ❑ Owner 0 Operator ❑ Fmplo)ce <br /> esignatedOpernor'sPhonon; 20q (op C(-ct33b Service Technician ❑ Third-Panty <br /> ternational Code Council C•ertitication#: ^ .� -- <br /> J_e`� � (I _ (j(` Expiration Date: - C - I <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: V Relation to UST Facility(Check one) <br /> Business Name(!f"ditrerent/tom above): <br /> ❑ Owner ❑ Operator ❑ Empluyec <br /> Designated Operator`s Phone : ❑ Service Technician ❑ Third-Party <br /> Iuaarnational Code Council Ccrutica[ion#: <br /> _ <br /> ALTERNATE 2 (optional) Expiration Date: <br /> — — <br /> Designated Clpermor's N;unr: Relation to UST Facility(('heck Oney <br /> Business Name(!/'diij)eren(from uhuvri: <br /> ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone ❑ Service Technician ❑ Third-Party <br /> International Cede Council Certification#: <br /> Expiration Dane: <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 .1715(c)'- (t). <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 Print): <br /> SIGNATURE OF TANK OWNER- <br /> DATE: / a / G j OW NEWS PHONE#: ZG j"?j <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD) BY JA:Nt ARY 1,2005, THE LOCAL AGENCY LIST IS AVAILABLE <br /> A T; <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFOR:YIATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br />