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Ld <br /> AUG 2 6 2009 <br /> Owner Statements of Designated Underground Storage Tank (UST)0pgtox <br /> and Understanding of and Compliance with UST Requi <br /> reMegtk-1 TAL <br /> "EPA RT�,4f�k,7 <br /> Facility Narne: Ko <br /> I Facility ID <br /> Facility Address' 'I IC)C)5. trbC((� (Check One) <br /> Reason for Submitting this Form(Check One) <br /> Change of Designated Operator <br /> Facility Phone 0 X lfpdate Certificate Fxpiration Date <br /> Desimated UST Overatods)for this Facility <br /> PRIMARY <br /> Designated Operator's Name;Karen R Axnaiz Relation to UST Facility(Check One) <br /> Business Name(1fd&rentfrom above)- 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#--(209) 518-4836 0 Service Technician X Third-Party <br /> International Code Council Certification#,8032295-UC Expiration Date;06/20/2011 <br /> ALTERNATE I(QpdonaO <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If&fferenrfrom above)., [I Owner 0 Opemtor 0 Employee <br /> Designated Operator's Phone#; C) Service Technician 0 Ibird-Party <br /> 4hotruational Codc Council Certification#; Expiration Date, <br /> ALTERNATE� (Qpjjonq) <br /> Designated Operator's Name: Relation to UST Facility(Check,One) <br /> Business Name Qfdifferenf from above): D Owncr C1 Operator Cl Employee <br /> Designated Operator's Phone C 0 Service Technician q Third-Party <br /> International Code Council Certification 0: 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 employee 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 /> IKOWNER(Please Mnt):_/<UZ-1) Cot P S111q1�1P14Zqj-t31R 4M 09 <br /> OF'TANK OWNER: <br /> I;DA1T7'E,: PHONE <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> V -�jg� <br /> AT: wxvv-� �IeL &.L a <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />