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021j 1 15, 2011110: 53AM98873a01- KAREN ARNAIZ N4, 0634 P,P, 2 02107 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operat*i <br /> and Understanding of and Compliance with LIST Requirements 20/1 <br /> facilely Nsmc: . a Fhcility ID#: <br /> Facility Addttiss' Reason Ior Submitting ow Fom(Check One) <br /> Change of Designatcd OpMtor <br /> Facility Plioue# x Update Ceroficaw Expiration.Daze <br /> Des" ted VST OperaY tqxjA for this Facie <br /> PRIMARY <br /> Dostggaaed Operator's Npnw Kstren R AmaU PAation to UST FRcility(Check URe) <br /> Business Name(YdVerentfrofn above): 0 Owner O Operator © ,FMVIOyee <br /> Designated Oporatoel Phone L(299)51.84836 0 Service Technician X TWrd-Yatty <br /> ]ntw-national Code Council Cettil"ication#-80321-95-UC Expiration Date:06/11/,20113 <br /> ALTERNATE I O tions! <br /> Designated Operator's Names: Relatlon to UST Fullity(Check One) <br /> Business Name(Ifdoer"from above)- ❑ Owner 0 Operator ❑ Employee <br /> Designated Operator's Phonc#: ❑ Scrvtco Techtlicjan ❑ Third-Party <br /> #>tutemalond Code Cowd Cevtif=ion A. Expiration.tante' <br /> ALTERNATE r (Optional} <br /> Deaignared Operator's Name: ReWon to UST Facility(Check Ogre) <br /> DuslnessName(Ordtferenrfrom.above): O Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone W: ❑ Sei-vice Teftioistt ❑ Third-Parry <br /> International Code Council Certification#; Expiration Datc: <br /> I certify that, for lite facility:judicated at the top of this pago,the individtml(s) listed above will <br /> serve as Designated UST Operator(s). T-he in ivicituil(s) will conduct acrd document monthly <br /> facility inspections and awtial facility CMployeo training,in awordance wish California Code of <br /> Regulations, title 23, section 2715(c)- (t). <br /> Furthennore, l twdelstaud and am in compliance with the requirements (statutes, <br /> regu.Iatitous, and local ordinances) applicnble to underground stole tanks, <br /> NAME OF TANK OWNER.(Flease Prlut): <br /> SIGNATURE OF TANX OWNER: <br /> DATE: OWNER'S PHONE <br /> NOTE: 1)SUBMIT THIS COIVa. LI✓TU FORM TO TIV-LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL,BOARD)BY JANUARY 1,2005,THE LOCAL AGENCY. LIST IS,&VA,ILABLE <br /> AT:www,vraterbosrds.ca. ok y/ust/contactsicuca aQys.htnil. <br /> 2)NOTIFV THE LOCAL AGENCY OE ANY CHANGES TO THIS INFORMATi0N VSrI`f'1<IIN 30 DAYS <br /> OF THE CHANGE, <br /> November 2004 <br />