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Jan 22 10 12:20p Reliable PetroleumA 209-845-8953 p.3 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator. <br /> and Understanding of and Compliance with UST Requirel-nents <br /> !•acuity Name: � ---.-- <br /> Eacilit% Address: Facility ID#: <br /> —'— ---- � IZea,on for Submitting this I'urrn(('heck()nc•} <br /> :ccilit) Phonc u; _ ❑ Change of UcsignatcCi Operator <br /> —' -���~ ��--��ZZ —��- Ilpdatr[:crtiliwte Ftpirrtiun <br /> Date <br /> YKI,LLARY <br /> Desi nated UST Oneratorls) for this Facility <br /> _ —�- <br /> I)c:si�nated <br /> Ilusineas Name q/d!,*tfe <nl lrnr+uhucr/ I �Lk <br /> Relation lu l.!ST F:tcilitt(!'hec'K Oncl <br /> � e � �'�` `it$ Owner C7 ( rrator Q Employee <br /> l)ctiignated Operator's Phone : Z(� - .- <br /> ` Sfr�y—i 33 J-Set%ic:Trchnici:tn ❑ f hied-P:utp <br /> Intemutional Code Council Certification : �a <br /> 5� uta E:xpirutiun Date: 7 l ZU j+ �— <br /> ALTEKNATE 1 O !Puna! - — <br /> De%ignatt:d Operator's Name: <br /> Liusincss ti:tnte 1I/drJJerent-jiont uhove). -- TRolation to UST Facility(C'wncr ❑ Oherttor Q Empfoyec;Dceignated Operttor's Phone 4: <br /> ervice Technician ❑ Third-Party <br /> �IntccrnatitL)�na](Code Council C'rrlitication k: <br /> ALTERNATE 2 /Optionrr!) EXpirttion Date: <br /> DL;ignatcd Operator's name: <br /> Business Nitme !•dr,' err�rl/rnm above): <br /> Relation to CiS7'Facility I C'/:ecK f:)ne) <br /> (.j JI' <br /> ❑ Owner ❑ Operator ❑ EmpIu�ec <br /> Dalignated Operator's Phone#; <br /> Intematiu` naE(udr Council(enitication jt: ❑ Service rechniciun ❑ Third-Party <br /> Expiration Date: <br /> FIT certify that, tar the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Uesibnated [.1ST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee. training, in accordance with California Code <br /> Regulations. title-23. section 27I5(c) - j t). of <br /> i <br /> I Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks, <br /> I NAME OF TANK OWNER(Please Print): <br /> ! <br /> SIGNATURE OF TANK OWNER: yC <br /> i <br /> � I <br /> DATE: OWNER'S PHONE 4: 40 <br /> NOTE: 1)SUBMIT THIS CONIPLETED FORM TO THE LOCAL AGENCY' (NOT THE STATE WATER) <br /> RESOURCES CONTROL BOARD) BV JA i(:ARY I,2005. THE LOCAL AGENCY LIST IS.,XY'AILABLE <br /> 2) NOTIFY THE LOCAL AGENCV OF ANY CHANGES TO THIS INFORNIATfON WITHIN 30 DAYS <br /> OF THE CHANGE. <br />