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JAN 26-2019 <br /> SAN JOAM N COUNTY <br /> ENVIRONMENTAL <br /> TMEbLT <br /> Owner Statements of Designated Underground Storage Tank (UST)T�crag <br /> tor <br /> and Understanding of and COmpliance with UST Requirement <br /> trMAR 9 <br /> R❑F�n�w4n'�+mwr S*ou:f <br /> bDmeidtri�nauvtandb tyFpomrm.�(C <br /> heck One) <br /> ❑ U CatdHoie oa Aw <br /> De.siaairii <br /> ted Y1CT OralWs)for this ar--:: <br /> tty <br /> PaIMARY —__ <br /> balartaeed Oper"tar'"Name: R"latloe to UST FacWty(Cluck One <br /> Dmb=Name(,Vdt ',,m obour): ) <br /> ❑ Owl ❑ Opt " ❑ '0'�*eted Oper"+or'e FMoo"M: - •� /" ❑ Serooe TechntcM- <br /> _party <br /> Iefrnetioaal cab Coandl Cadeomloo a.—./ C E iratiou Dao"; r- <br /> ALTERN <br /> Deai�"oed 's Name: Beletlon to UST Facwty(Check One) <br /> OCRr ro.r irbmy• ❑ Owner ❑ OP.M' ❑ Employee <br /> Desitaaead Opawtor•a Mono 0: /(i- ' 71-,?3A:) ❑ Service T"choicim J�'Thhd-Prty <br /> .fotet SUMW Code Coonoll Cunasuion <br /> ALTERNATE (Opdoacy <br /> Dadgnued Opmtmr's Nana: ReLtim to UST Fadlity(Check One) <br /> Rtalaeu Nam(if d(p"erau abow,l: ❑ Owner ❑ Operator ❑ Flaploy« <br /> Ded�ed Opmator4 Phone#: 9/G - ❑ Seevioe TeabnICI o at Third-Pty <br /> lntaadional Coda Council Cmd9cauon 0: ,f' 7 G Expfntlon Dete: -�p D// <br /> I cerdfY 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 in <br /> and annual facility employee training, in accordance with Califomia Code of <br /> Regulations, title 23, section 2715(c)-(fl. <br /> Furthermore,I understand and am In compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to onderground storage/tanks. <br /> NAME OF TANK OWNER(Pias"Print): r�I �&- nk Y I KV o34p, , t (j C <br /> SIGNATURE OF TANK OWNER.- <br /> DATE: <br /> WNER:DATE: I ' o ID OWNER'S PHONE#: y�0 l�U n7) Lf g <br /> NOTE: 1)sMrdTT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT TRE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2003.THE LOCAL AGENCY LIST IS AVArr. BLE <br /> AT:www coat rho .&ca ne /. / t / iR.rstsLhSrnl• <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />