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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Act <br />Facility Name:�' krr � j✓ , ,� d f {; �J� <br />Faeil ity ID #: P A Oo�� rr6 <br />� <br />Facility Address: <br />Reason for Submitting this Form (Check One) <br />2yo S. c_�,e_o y _. e_ <br />i, Change of Designated Operator <br />Facility Phone #:�ESO% <br />Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator'— s Name: I <br />Relation to UST Facility (Check One) <br />❑ OwnerOperator ❑ Employee <br />11Service echnician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Ccrtification #: ^��J <br />ExpirationDatc: 3 -13-.-- C) 1 <br />ALTERNATE i (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner 0 Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name ffdi#Arentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Narne: <br />Relation to I1ST Facility (Check One) <br />p Owner ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third -Party <br />Business Name (lf different from above): <br />- <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Lute: _ <br />1 c•.ertify 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 />NAME OF TANK OWNER (Please <br />SIGNATURE OF TANK OWNER: <br />DATE: L� ?- —— - -- OWNER'S PHONE #: O % 3 6f ✓ 1 Co <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 A'V'AILABLE <br />AT: M w•_.waterboards.cagov/ust/contacts/cupa agys.htrnl. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />