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Jan 11 07 03: OGp P• 1 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: t_ �ti Nc+\1 — •_ Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> L Change of Designated Operator <br /> Facility Phone#: :3C`1 `6�C q Q ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: C. Relation to UST Facility(Check One) <br /> Business Name(If r4gerent from above): ❑ Owner ❑ Operator Arl Employee <br /> Designated Operator's Phone N: _ ��t� � 7 D Service Technician ❑ Third-Party <br /> InL .ternational Code Council Certification#: 501 Cly L r5 Expiration Date: 5 <br /> ALTERNATE 1((Ptinnal) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If a96rerent from above): ❑ Owner n Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification ti: Expiration Date: <br /> ALTEMNATE 2 (t)ptim d) <br /> Dcsignatcd Operators Name: Relation to UST Facility(Check One) <br /> Business Name(If AT'erent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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 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 TANH,OWNER(Please Print): <br /> SIGNATURE OF TANK OWNE$'�— <br /> G <br /> DATE: 1 a - i G OWNER'S PHONE is: <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:��t�u.��alcrbc�.irds.ca. m/usUcontacts/curr au%•'.htntl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />