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Owner Statements of Desipated Underground Storage "Fank ([1ST) Operator <br />and Understanding of and ('ompliance with UST Requirements <br />Nat"; R e- 0c, � <br />F�aoiIity N <br />_ - - / /Y%f-rnR Facility 11.) 0: <br />FuoilityAddroxx; , �y,� �C� l._.._. 0 -heck <br />) <br />(�+� � " � de1i� �'�"�,� Reason tirr ;submitting this ] n+7r (l"heck (.7n�>) <br />sfoc l< on t C� 9s�/ C:bnngo ot'lk34sig,i,ntcd lllnsrofus- <br />�' I ucilily PLcn�r R; AL1 �- �%S �� ISS I? . At0 Cofh fiiontc lix rimt+nn Dntu <br />Dlesistrr r r foijbiLF-acility <br />PRIMARY- <br />DoWgnatod Operator's Nano: A'Ae- Relation to us'r Facility (.Check 0n+ .) <br />HusineHa Name Ufdfforent fr»tn above) 61 a py , ❑ t )wtio n Operi for n ltu phtvre <br />I)exigpatcd 0perntor'x I'lime ll.; ZQ9..- f` a Servio0cohiticiatt A 'A*hird•l'arty <br />~ International Cndo (;ouncll C:oMficatim t1, Mtc; ') <br />AL'URNATE 1 O Jon <br />Doxignatod Operator's Name: Br4MA6111 ReWon u) UST Facility (('hock (Joe) <br />L FivainosA Name (I/dfjerent/rant 4Mve): t9y%rEC_ �v�►'t �A, n t wear n t perntor n l an pinyca:. <br />.. . ...._ <br />^Deeignutwl Opuruwr'u Phono 11: eOf-Sj�, 9 Qli-TM "T -y ' U Svrvicu'i'ochnician .Third-1'any <br />lntornational Ccxlc Council C:or(ificalim N; � �S-��. Lxpiralion talo: `2- /-261c) <br />._------.-� 1.9.E .. ----------- -- _.-_. _._..---... <br />AL'I'L RNATF x (Opliona4----.-•---.- <br />Dedgnuwd OpmLor"o Nut o. rl m�Coyltllpe* <br />Al Rolation to UST Facility (Check One) <br />l?luxi�xxxNRlllc%(.lfd{�frranln�uia ❑ Owner ❑ Operator ❑ 1':mployre <br />Designated Opcmtor'A phone t,'; _� f� — d 50rvicu'1'u lutician '1'hircl•I'nrt}_ <br />Inlernnknial Code Council lih-anon ll; d?Plu !T -V Lxpiratiun Duta: <br />NOTE: THE LOCA EGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANCES TO THIS <br />INF'ORMA ON WITHIN 30 DAYS OF THE CHANGE, <br />G•3 G <br />.- too l � ... _3_-U .__.._.�. .�. _..�. <br />l 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 />NAME OF TANK OWNER <br />OR OWNMIS AGENT (Plcoae Print): <br />SIGNATURE OF TANK <br />OWN OR OWNER'S AGENT: _: -- ---- <br />7)ATE: OWNER'S PITONS 0: <br />V6 Wd6E:L0 600E 80 'add 8606L2S60E: 'ON XUA <br />Septcmhcr 2004 <br />oo dwnd aaluoQ: W06j <br />