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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: rQc,. + Facility ID#: <br /> Facility <br /> `Address: I Reason for Submitting this Form(Check One) <br /> Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: On ;:;n+arj01 Relation to UST Facility(Check One) <br /> $i,cinrcc Name(jfdi Brent from above): J ST Q ►CAnCQ. �C5+jn ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: �( Service Technician ❑ Third-Party <br /> International Code Council Certification#: (�{ _ V Expiration Date: C. -a3- l <br /> ALTERNATE 1 Bond <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): 7, e ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: _S _-!54Cj 1Service Technician ❑ Third-Party <br /> International Code Council Certification#: _.UC. Expiration Date: l - <br /> ALTERNATE 2 (OpdonW) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If di,fjerent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> international Code Council Certification#: Expiration Date: <br /> I certify 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 inspections and annual facility employee training, in accordance with California Code of <br /> Regulations,title 23, section 2715(c) -(f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to erground storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: '� OWNER'S PHONE#: <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 AGENCY LIST IS AVAILABLE <br /> AT: vuww.waterboards.caguv/usticontacts/cupa ay <br /> ys.hinil. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />