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RECOVED APR 2 9 2009 BWONMENT HEAU H PRMIT/sEftv"s Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: C��" V ` ------ - Facility Address: + C h f��e'�fl Facility ID#: O Reason for Submitting this Form%('/reek One) Trt �l- • 53��`�_ Facility Phone H: (�h� � _ X Change of Designated Operator �---- ❑ lJpda[r Ccalificate Expiration Date PRIMARYDesignated UST Operator(.) for this Facility Designated Operator's Name: Business Name(ff tyi rent Jrom shove): t Relation to UST Facility((heck pare) �� L� ❑ Owner ❑ Operator ❑ Em Io re Designated Operator's Phone#: P Y International Code CouncilCertificatiun#:�G14 - fn v �3� ServiceTechnician ❑ Third-Party ALTERNATE I (optional) 5a�sk4C —O c- -xpiration Date: --C ._C9-0! Designated Operator's Name: Business Name(/j*d�.fferent from above): Relation to I1ST Facility((:heck One) Designated Operator's Phone#: ❑ Owner ❑ Operator ❑ Emplovee International(:ode Council Certification#: ❑ Service Technician ❑ Third-Party ALTERNATE 2 (Optional) Expiration Date- Designated Operator's Name: Business Name(Ifdierent from above): Relation to UST Facility((heck one) Designated Operator's Phone#: ❑ Owner ❑ Operator ❑ Employee fnternational Code Council Certification#: ❑ Service Technician ❑ Third-Part) Expiration Date: ---------------- ------_— I certify that, for the facility indicated at the top of this serve as Designated UST Operator(s). The individual(s) lel t conduct and documenthe individual(s.) listed above will facility inspections and annual facility employee training, in accordance with i California Code Regulations, title 23, Section 2715(c) - (t)• de of Furthermore, I understand and am in compliance with the requirements (statutes regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): iJ SIGNATURE OF TANK OWNER: i � DATE: tf D 011 N ER'S PHONE#: (� _ ' - 3� Zt � � � 40 � • (036 - (o�S NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE W RESOURCES CONTROL BOARD) BY JAN( I,2b05. THE LOCAL AGENCY LIST IS.A�' RE WATER . AVAILABLE 2) NOTIFY THE LOCAL AGENCh'OF ANY CHANGES TO THIS I N FORMATION WITHIN 30D.4 Y S OF THE CHANGE.