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9`t <br /> Operator Tank (UST) <br /> Statements Stateents of Designated Underground�ttho UST equyrexnents <br /> and Understanding of and Compliance <br /> Facility ID#' <br /> FacilityName: �D a� Reason for SubraWing <br /> facility Address' p0 Change of nesignatcd Operater x 4 <br /> 01,We Certificate Expiration Date <br /> Facility phone <br /> if <br /> Desi ated 'QST O rator s for this Facility sF✓JGa'� elf <br /> U <br /> PYt1MA1<tX' Relation to UST pacility(Check One) 0 '3,44'��Y <br /> Dcsjpmtcd Op <br /> erator's Name:Karen R Arnaiz ❑ Owner n Ope stor O Employee FNT <br /> Business Name(If drfferent from above)- ❑ Servjce T dmidw X Third Parts' <br /> Designated operator's Phone#:(209)5184836 Expittttion Dau:p(/j 1/2013 <br /> International Code Council Certification#:$032295-STC <br /> ALTERNATE I o oral Relation to UST Facility(Check One) <br /> Designated OPerator's Name' ❑ Owner ❑ Operator ❑ Employee <br /> Business Name(if di erenr from above): ❑ Service Technician ❑ `Third-Party <br /> Designated Operator's phone M. Expiration pate' <br /> Council CertiScaSnon#: <br /> #International Code Check One) <br /> ALTERNATE 2 (Uptfoteal) Rtlation to UST Facility <br /> Designated Operator's Name: p Owner ❑ Operator <br /> r3 Employee <br /> Business Name(1f dt�erent fr <br /> om above): ❑ Service Technician O Third-Patty <br /> tor's phone#' Epilation Dazs' <br /> Designated Opera <br /> International Code Council Certification#: <br /> the individuals)listed above will <br /> indicated at the top of this pall conduct and�umeut monthly <br /> I certify that,for the facility s <br /> The individual( ) ce with Califo�a Code of <br /> ated UST Operator( )' <br /> serve as Design d annul facility employee tram ' <br /> in accordance facility inspe�oxls � <br /> title <br /> Regulations, 23,Section 2715(0) _ W- mix-ements(statutes, <br /> compUauce witL toga storage tanks. <br /> TUrthermore,I understand and am inleto underground � �`� <br /> re ations,and loci'!ordananees) appli ab 1� L,A <br /> pE T <br /> NAME A <br /> OWCdER(please Mat) � <br /> SIGNAT01tE OE TANK OWNER: ,�- ` C �•, Y 7� <br /> OWNER'S'P1iONE#: <br /> DATE= STATE W ATER <br /> LOCAL AGENCY(NOT IIS <br /> pLETED EO .M TO T�5 TIDE LOCAL, GENCY LIST IS AVAILABLE <br /> t SUBMIT T11YS COM BY JANUARY 1,2 <br /> NOTE: ) ONTR4L BOARD) a vs_h 1, v 30 bA'YS <br /> RESOURCES C TION WI"[I; <br /> AT; ,uv,w.waterboard .ca.�ovl sticontacts cuANaY GANGES TO THIS INFORMA <br /> �-- AG AGE1`1CY OF <br /> z)NOTIFY TRE LOC November 200a <br /> O-F'TTIE CHANGE. <br />