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f <br /> FROM : MRNTECR LIQUOR AND FOOD FAX NO. : 209 239 4550 Dec. 30 2004 03:58PM P1 <br /> •F.l �ck-y <br /> Owner Statements of Designated Underground Storage Tank (UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nam:..tnAN 7,,d* 6 L�[r.� frrc� -Gn 1 Facility mD : <br /> Facihty Addmss:P 9a N MAt AI S+=L Reason for Submitting this Form(Cheek Um) <br /> ❑ ChangeufMsip3ted Operator <br /> Facility Phone d: d o y3 9- 4 S s a ❑ U 'le Ccrtiticate Expiradon Date <br /> Designated UST Ooerator(s)for this Facility <br /> PRIMARY <br /> Daippared Operator's Name: G4,p;,<27F'R T 5' Si4NDN(n Relation to UST Facility(Chrtk Ox) <br /> Business Namc(/fJrf'rrcni from above): ! Ame- V Owner ❑ Operator ❑ Pmployee <br /> Designated Operatoes Prone p: Z 9'a 3:-4 s S'C ❑ service Technician ❑ 'Third-Party, <br /> Intemational Code Council Certification M' Z"n Dspiratiun Date: <br /> ALTERNATE r LOMLowlN_�. <br /> Designatcd Operator's Name: Relation to UTI'Facility(Check One) <br /> Business Natie(Jf,*fo rat f van above): •• - ❑ Owner ❑ Operator ❑ Employee <br /> Designated Opemaa'v Phonc H; ❑ Service Todmician ❑ Third-Party <br /> __... ... .,., ._. ......y <br /> Intematiunal Code Council Certification P: Expiration Date: <br /> ALTRRNATF.2 (Opp maA - .W..... <br /> Designated operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Jf(Nferenrfram above): ❑ Owner ❑ Operator ❑ Bmployce <br /> Designated Operators Phone d; ❑ service TwImieiaa ❑ Third-Party <br /> International Code Council Certification H: 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 /> 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 <br /> OR OWNER'S AGENT(Please Print): GCtN t76JeT�C% S- SA >✓77 H(.r <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: la ' .30'U k/ OWNER'S PHONE H: '2 L4 <br /> September 2004 <br />