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owner Statements of Designated Underground Storage Tarek(UST) operator <br /> and Understanding of and Comp <br /> liance with UST Requirements <br /> O Facility ID#: <br /> )10Q Reason for Submitting this Form(Check One) <br /> Facility Name: p M), 9/ Sr <br /> Facility Address: '�y O Q D yr• Fig�7��t _33� � Change of Designated Operator/71 >q Nt L C>a <br /> ❑ Update Certificate Expiration Date <br /> Facility Phone#: <br /> Des ated UST Operators)for this Facile <br /> Relation to UST Facility(Check One) <br /> PRIMARY - <br /> Designated Operator's Name:John Courant - ❑ owner ❑ operator ❑ Employee <br /> Business Name(If different from above):Ca mi UST Services }{ Service Technician El Third-Party <br /> Designated operator's Phone#:(925)595-8230 Expiration Date: November 3,2008 <br /> International Code Council Certification#:5242457-UC <br /> ALTERNATE d Relation to UST Facility(Check One) <br /> ❑ Employee <br /> Designated operator's Name: [3 owner E3 operator <br /> Business Name(If different from above): <br /> ❑ Service Technician ❑ Thrd-Party <br /> Designated operator's Phone#: Expiration Date: <br /> International Code Council Certification#: Check One) <br /> ALTERNATE 2 (OPSanal) Relation to UST Facility <br /> Designated operator's ❑ Owner ❑ operator ❑ Employee <br /> BusName(f 1fI di erent from above): p Service Technician ❑ Thud-Party <br /> iness <br /> Designated operator's Phone#: Expiration Date: <br /> Intemational Code Council Certification#: <br /> page,of this the individual(s)listed above will <br /> I certify that for the facility indicated awe ndividual(s)will conduct and document Mon Y <br /> serve as Designated UST Operator(s). in accordance with California Code of <br /> facility inspections and annual facility employee training, <br /> Regulations,title 23, section 2715(c) -(f)• <br /> compliance with the requirements (statutes, <br /> underground storage tanks* <br /> Furthermore,I understand and am in hompl to u with t <br /> cab /1 <br /> regulations, and local ordinances) aff <br /> NAME OF TANK OYdNER(P►ease Print): <br /> SIGNATURE OF TANK OWNER' <br /> OWNER'S PHONE#: <br /> DATE: <br /> TIIIS COMPLETED FORM TO THE LOCAL AGENCY(NOT T�STATE WATER <br /> NOTE: 1)SUBMIT ARY 1,2005•THE LOCM AGENCY LIST IS AVAILABLE <br /> RESOURCES CONTROL BOARD)BY JANU <br /> T. <br /> wWW.\vaterboards.ca. ovlust contacts/cu a a s.htmL INFORMATION <br /> WITHIN 30 DAYS <br /> LOCAL AGENCY OF ANY CHANGES TO THIS IN O <br /> OF THE CHANGE. November 2004 <br />