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Mar 20 12 11:23p Reliable PetroleumA 20q-845-8953 p.3 <br /> Owner Statements of Designated Underground Storag4T-ank(UST) Operator <br /> and Understanding of and Compliance with UST requirements <br /> Facility Name: P t l tInt' rA Facility ID#- <br /> Facility Address: . OY�- // 55 reason for Submitting this Form(Check One) <br /> T } - Q53`1(o ❑ Change of Designated Operator <br /> Facility Phone#: 30cf—K35-7292 X Update Certificate Expiration Date <br /> -Desi mated UST Otverator(s) for this Facility <br /> PRIMARY <br /> Designated Operator s Name:Robert Barnhart Relation to UST Facility(Check One) <br /> Business Name(Ifd erentfrom above):Reliable Petroleum Services Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:209-644-9336 X Service Technician ❑ Third-Party <br /> international Code uracil Certification#:52550-UC Expiration Dat <br /> ALTERNATE 1 tional t <br /> Designated Operator's Name:Guadalupe Sanchez Relation to UST Facility(Check One) <br /> Business Name(yd, Brent from above):Reliable Petroleum Services Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator s Phone 9:209-604-9363 X„Service Technician ❑ Third-Party <br /> International Code GPuncil Certification#:5250451-UC Expiration Date:01/29/2013 <br /> ALTERNATE 2 (C phone!) <br /> Designated Operato s Name: Relation to UST Facility(Check One) <br /> Business Name(Ifd erent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operatot s Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code C puricil Certification#: Expiration Date: <br /> I certify that, fe r the facility indicated at the top of this page, the individua.I(s) listed above will <br /> serve as Desigr ed UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspect'bris and annual facility employee training,in accordance with California Code of <br /> Regulations, tit a 23, section 2715(c) - (f). <br /> Furthermore, understand and am in compliance with the requirements (statutes, <br /> regulations, ain local ordinances) appliea to underground storage tanks. <br /> NAME OF TA OWNER(Please Print): ?%�P, <br /> SIGNATURE Of TANK OWNER: <br /> DATE: r' I Z OWNER'S PHONE <br /> NOTE: 1)SUBM THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CNTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: ww-waterb rds.ca. ovlust(contacts(c a at vs.httnl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHAN E. <br /> November 2004 <br />