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Dec 09. 09 01:25p Reliable PetroleumA 209-845-8953 p.2 <br /> Owner Statements of Designated underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> - ---- __ <br /> acitilyFR. <br /> • YFilcil <br /> l aei[ily:1ddrexs: GQ -omen for Submitting this I'urm r('lrrc•k Om•j <br /> I Change offh_-sign:ued Operator <br /> L Facility Phone it: Zt 5 (,, <br /> l:)pdate C'crtiticate Expiration Date <br /> Designated UST O erator s for this Facility <br /> Plt1.k1ARY <br /> Designated Orwrator'. Name- — — —' - ------- <br /> -- - Relation to UST F:u:ilit, f C'lrurk OrrrJ <br /> Business Name(/J dr/r r�nt!rant ubuve�): <br /> �3 I� rd m — t' ❑ Owner ❑ operator ❑ limplo)ec <br /> f)csignatcil()per for:Phone#: �!t —��Q�Q��� �g( Service Technician ❑ liiird-Party <br /> International Code Council Ccrtitication I7G^ p. -- <br /> - — Ex iration Date: <br /> ALTERNATE l (Oprirraa!) <br /> Designited Operator's Name: a l Relation to l!S"i'Facility((-'heck(JneJ <br /> B usiness Ntune i 9 fferent from above.). <br /> ❑ Owner ❑ Operator ❑ Employee <br /> Ilesi�nated Operator's Phone#: ❑ Service Texhnician ❑ f laird-Party <br /> Inlcrnational Crude Council Certification 4: —Expiration Date: <br /> ALTERNATE 2 (Optionu!) <br /> Ur,ignateJ C)perator's Name: — Relation to UST Facifitt(('heck One) <br /> Business Name(/I c/iffirc•rrt fi-nnr cr6avri: <br /> —_ ❑ Owner ❑ Operator ❑ Fmployee <br /> Designated Operator-s Phone q: 0 Scrvicc'rcchnician ❑ 'third-Part. <br /> fntemational Code Council C'ertitication 9: — <br /> — _ Expiration Date: <br /> I certih, that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated UST Operator(%). The individuaI(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 '7L5(c) <br /> IFurthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> i <br /> k NAME OF TANK OWNER(Please Print): 3.0+Sa1,e C-HPoD <br /> SIGNATURE OF TANK OWNER: <br /> DATE: J2-- 2--y OWNER'S PHONE <br /> t <br /> NOTE: 1)SUBMIT THIS COti-IPLETED FORA TO THE LOCAL AGENCY (NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD) BY JANUARY I, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br />