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Dec 28 04 04: 58p Ai - a Sibley - Sr. HSE Co 70^ 452-8947 p. l Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of Compliance with UST Requirements Facility Name-Y-"13(y 4 Facility ID#: 3(u /�{4 Facility Address: �, Reason for Submitting this Fonn(Check One) �� i Op X Change of Designated Operator Facility Phone#: 0 Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: S H�LLe S�(�9 C Relation to UST Facility(Check One) Business Name(ydperentfromabove):pLLryl �Uvino�iyc� TRC Coi r� ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: c�L S -Sot - ❑ Service Technician X Third-Party International Code Council Certification#:vuava,cnusce Expiration Date: A —� ALTERNATE 1 o Designated Operator's Name: C rz 1 2, (, Relation to UST Facility(Check One) Business Name(Ifdrfferent from above):0,t_r Uvi✓C�u)�,e,v Co",)L F_1 Owner ❑ Operator 0 Employee Designated Operator's Phone#: i� - 7 L -06 `� 0 Service Technician X Third-Party International Code Council Certification#: 5-kq 3 _ v L Expiration Date: 9 )_y 2 p C ALTERNATE 2 onqR Designated Operator's Name: r> ,„(2 V n.)t)-e rt P L.✓ (41-5 Relation to UST Facility(Check One) Business Name(Ifdifferentfrom above):,), 4 ��2F Uz- ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (,3 -C Lis 6 7.3 ❑ Service Technician X Third-Party International Code Council Certification#: 3 6 — U C Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations,title 23, section 2715(c) -(f). Furthermore, I understand and am in compliance with the requirements (statutes, 1 regulations,and local ordinances) applicable to underground storage tanks, NAME OF TANK OWNER(Please Print): Aa ll S/,6 -1, SIGNATURE OF TANK OWNER: SCJ L� � I DATE: OWNER'S PHONE NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: w-mv,Nvaterboards.ca p,v/usUcontacts/cupa agvs.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.