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i <br /> Oct 12 10 02:01p Reliable Petrolew 20165-8953 p.2 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> al id Understanding of and Compliance with UST Requirements <br /> Facility Name: f– 11 Facility ID#: <br /> Facility Address: I!4 9�, k jt�Y, Lane Reason for Submitting this Form(Cheek Orm) <br /> cal [A. i7 & )( Change of Designated Operator <br /> Facility Phone#: — ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY _ <br /> Designated Opera or's Name: � n, d "r: Relation to CST Facility(Check One, <br /> Business Name(Iji , i lrom above):. , e Olt' Owncr ❑ Operator ❑ Employee <br /> Designated Opera r s Phone _ !733 01I.Service Technician ❑ Third-Pavy <br /> Intemational Cod Council Certification#:�j-aS U –14 ('j Expiration Data: . �� ) 3 ;.fid®% <br /> ALTERNATE 1 O tivAul <br /> Designated Opera is Name: Relation to UST Facility(Check One) <br /> Business Name(! rtrJ)erenefr•om above): ❑ Owner G Operator C Employee <br /> Designated per <br /> is Phone#: ❑ Service Technician ❑ Third-Pavy <br /> Imernational Cod Council Certification#: Espirdlion Date <br /> ^ ALTERNATE2 Opriond) <br /> Dcsiena[cd Operat <br /> Ws Name. Relation to UST Facility(Check One) <br /> Business Namc(1J Q]ereni ftam ahave,: ❑ Otsmer ❑ Operator ❑ Employee <br /> Designated Opera is Phone h: ❑ Service rechnician ❑ Third-Party <br /> Intematianol Code Council Certification k- Expiration Date: <br /> I certify that, r the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Desi noted UST Operator(s). The Individual(s)will conduct and document monthly <br /> I <br /> inspec 'ons and annual facility employee training, in accordance with California Code of <br /> Regulations, ( le 23, section 2715(c) <br /> Furthermore I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicabl o underground storage/tanks. �G <br /> NAME OF TANK OWNER(Please Print):C1GL �+ `ltih' GLS <br /> SIGNATURE OF TANK OWNER: f �� // n ,r /� <br /> DATE: � NER'SPH NE#: TC � �a(-7yy <br /> NOTE: 1)SU BN IT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br /> RESOURCES C NTROL BOARD)BY JANUARY I,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: •.+•.•. xlrbiards,ea,g,o,..aia_cnn!.ttJz yapp_;•z. _Ilcri. <br /> 2)NOTIFY THLOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN'30 DAYS <br /> OF THE CHAN E. <br />