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J,pn,2?. .0 12:20p Reliable PetroleumA 209-845-8953 p.4 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements FacilityName: Facilitv ID#: Facility Addrem: 1 f t)0 t-AST. Reason for Submitting this Form(Check One) Change of Designated Operator Facility Phone#: Zp — 'RA15 (e-7 q ❑ Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Relation to UST Facilit4(Cheek One) Business Name(I olferent from above Itdwt. Tittl"vner ❑ Operator ❑ Employee Designated Operator's Phone 4; 201 - to Lf 33(P )t Service Technician ❑ Third-Party International Code Council Certification 4:52 Expiration Date: f'j-- 7-13 O ! ALTERNATE 1 (Optional) Designated Operator's Name: Relation to UST facility(Cheek Once Business fume(Tf diferent from above): C Owner ❑ Operator ❑ Employee Desi,gnated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certiticadon#: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone 4: ❑ Service Technician ❑ Third-Party International Code Council Certification k: Expiration Date: 1 certity that, for the facility indicated at the top of this page,the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c)-(f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): J FFS�s lR C yf)`t)`D SIGNATURE OF TANK OWNER: DATE:Sb. / dQ t(,/ OWNER'S PHONE A: NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY I,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: li ^t-,r?_08ri!�..�:a. _ _..... -._.. __....._.._.e.._ 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.