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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST R.equiremel 2 <br /> Facility ID r?f: � ��), .� <br /> Facility�Narne: ,� Reason for Sbmitting tbiz.#0.fj. ckOne) <br /> facility : 77W <br /> r CK <br /> 1, <br /> Change of Designate, <br /> X Update Certificate F, it ' <br /> Facility Phone# <br /> Des' Hated UST erato s for this Facility <br /> PRIMARYCheck One <br /> Designated Operatar'sNarne:Karen R Arnaiz <br /> Relation to UST Facility( ) <br /> om above) <br /> ❑ Owner 0 Operator ❑ Employee <br /> Business Name(If differenr f <br /> El Service"i'cchnician X 'Third-Party <br /> Designated Operator's Phone#:(209) 518-4836 )expiration Date:05/20/2011 <br /> International Codc Council Certification#:$032295-UC <br /> ALTERNATE I O ti may <br /> 12elation to UST Facility(Check One) <br /> Designated Operator's Name: ❑ owner ❑ Operator ❑ Employee <br /> Business Name(If different from above): <br /> ❑ Service Technician ❑ Thud-palt'1' <br /> DCQgratcd Operator's Phone#' <br /> Expiration Date: <br /> #International Code Council Cffffl cation#: <br /> ALTERNATE. Z (QPdond) Relation to UST Facility(Check One) <br /> Desig e,ted operator's Name: <br /> p Q.vner ❑ Operator a7 Employee <br /> Business Name(If differenr from above). <br /> ❑ Senice Technician ❑ Third-Farcy <br /> Designated Operator's Phone#' <br /> Expiration Date: <br /> International Code Council Certification#: <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 individuals) <br /> 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) - (�• <br /> Furthermore,Y understand and am in compliance <br /> cable to undergroundst rage tanks(Statutes, <br /> regulations, and focal ordinances) apPh L -Td -19– <br /> _ITU n „r(;; uc <br /> NAME OF TANK OWNER(Please Print <br /> SIGNA'T'URE OF TANK OWNER: <br /> DATE: *)(LQ— <br /> O'WNER'S PRONE#: <br /> FORM TO THE LOCAL AGENCY(NOT THEE STATWATER <br /> NOTE: 1)SUBMIT THIS COMPLETED <br /> I,1 <br /> GENCY OF ANYCHANGES TO THIS INFORMA045.T>EIE LOCAL AGENCY LIST IS AVAILABLE <br /> CONTROL BOARD)BY JANUARY <br /> AT: A WW.wat rboa►•ds.ca�o�'/ust/con cis/cu a s htTION v�rIIHIN 30 DAYS <br /> 2)NOTIFY THE LOCAL A <br /> OF THE CHANGE. November 2004 <br />