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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance With UST Requirements <br /> FaciligName:. S'Qq_4Ic Facility 1D R: <br /> i Facilit) Address:. (,l�^�• .e•, m \t(� S+(-, j Reason for Submitting this Form rC'heekOw) <br /> '• sArocjp_T , CIO - iS —f a Change of Designated Operator <br /> Facility Phone=: _ - _�it+t'l—lt..i� NM 1:pdate Certificate Expiration Date <br /> Designated UST Ouerator(s)for this Facilitv <br /> PRIMARY <br /> Designated Operators Name:Greg Kaiser Relation to UST Facility(Check Ones <br /> Business Name iIj difereut from antwe,:A;vser Commercial Perroieum ; D Ot+ner G Operator 13 Employee <br /> Designated Operator's Phone=:209-401-2379 G Senice Technician e. Third-Park <br /> ' International Code Council Cenitication=:5252318 Expiration Date: 10172017 <br /> .ALTERNATE 1 lOndioaal) <br /> Designated Operators Name:Stephanie Aklurph3 Relation to UST Facility tCheck One/ <br /> Business Name ill-dtireran from ahorei: Kaiser Conimer cud Petroleum —� ` pi, n Operator M Emploa-ee I <br /> Designated Operators Phone%:209-88'-2639 0 Service Technician S rhird-Party j <br /> international Code Cmnti1 Certification=:00242884 Expiration Date:10;28,2017 <br /> ALTERNATE 2 (Optional) -- --- - <br /> Designated Operators Name- Relation to UST Facilinv(Check One, j <br /> BusinescN;ame -_r Ot%ner M Operator 8.. <br /> Employee <br /> Designated Operator's Phone=: —~ Service technician 0 Third-Part} , <br /> ;ntemational Code Council Certifimiett=: j Expiration Date' f <br /> I <br /> I certify that, for the facility indicated at the top of this page,the individual(s)listed.above will <br /> serve as Designated LST 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). i <br /> Furthermore, I understand and am in compliance With the requirements(statutes, i <br /> regulations,and local ordinances)applicable to underground storage tants. j <br /> NAME OF TANK OWNER(PleasePrue � .j -�/j1"�%. 7 ( • > /�iY <br /> SIGNATURE OF TANK OWNER: <br /> DATE: rL'� 1�.._._ OWNER'S PHONE : <br /> I <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AG ENCY LIST IS AVAILABLE <br /> 2);NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 1-004 <br />