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-To , W-9- L_ /-- 7w-, NC <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: . C 0 6' f� Facility ID C <br /> Facility Address: ��C - i �G Reason for Submitting this Form(Check Orae) <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: Karen R Abbott Relation to UST Facility(Check One) <br /> Business Name(If different from abave),- ❑ Owner © Operator C Employee <br /> Designated Operator's Phone 4:(209)5184836 ❑ Service Technician X Third-Party <br /> International Code Council Certification 9:5266643-UC Expiration Date;10/12/07 <br /> ALTERNATE I(Optional) <br /> Designated Operator's Nante: Relation to UST Facility(Check One) <br /> Business Name(If different from above). ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#; C Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check Orae) <br /> Business Name(Ifdlffereni from above): ❑ Owner ❑ Operator [i Employee <br /> Designated Operator's Phone#: R 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 employc>e 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 underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): �j -, — rj `.S/—) �/ <br /> SIGNATURE OF TANK O'W'NER: <br /> DATE: l 1 7y� �_ OWNER'S PHONE#i:L:lc <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,Zoos.TIME LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.cov/'usticontacts;'cupa acvs,himl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> TO DgVc1 LGZZ9C86©Z 9T :EZ 50©Z/9E/ZZ <br />