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Mar 19 10 09:54a Reliable PetroleurnA 209-845-8953 p.3 <br /> to <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name' ti 1 ,111,11,11 Facility ID#: <br /> Facility Address:t t �, 'e. <br /> Benson for Submitting this Form(Check One) <br /> ® i_ tJt` 77 X Change of Designated Operator <br /> Facility Phone#• - _ ❑ Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: -�l1el' t1.I'Yl. ' I - Relation to UST Facility(Check One) ` <br /> Business Name(Ifdrferenlfrom above)'., � � � 1' 601 St2rilt. ' Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone ® _ A <br /> • a3' . ¢l,Service Technician ❑ Third-Parry <br /> International Code Council Certification 9: $c� — G Expiration Date: , <br /> ALTERNATE I ( nional <br /> Designated Operator's Name Relation to UST Facility(Check One) <br /> Business Name(U'diferenrfromabove): ❑ Owner ❑ Operator ❑ Employce <br /> Designated Operator's Phone#: ❑ Strvice Technician ❑ Third-Party <br /> International Code Council Certification+!: Expiration Date: <br /> ALTERNATE 2 (OptlonrdJ <br /> Ih:signated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): C Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> Ft, for the facility indicated at the top of this page,the individual(s) listed above will <br /> signated UST Operator(s). The individual(s)will conduct and document monthlyections and annual facility employee training, in accordance with California Code of <br /> ,title 23, section 2715(c, - (f). <br /> Furthermore, I understand and am in compliance with the requirements(statutes, <br /> regulations, and local ordinances) applicabl o underground storage tanks. 76 <br /> : NAME OF TANK OWNER(Please Print): r, GLL "111_41 <br /> SIGNATURE OF/TA,NKOWNER- <br /> LDA <br /> WNER- �7 <br /> DATE: NER'S PH NE k: ?e' <br /> ;VOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,21105.THE LOCAL AGENCY LIST IS AVAILABLE <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANCE. <br />