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07/27/2011 23:19 2094655290 ABC FOOD MART ;Psw $A� 01!02 <br /> JUL 2 8 <br /> Owner Statements of Designated Underground Stora ank(UST) Op o"ul,cou <br /> and Understanding of and Compliance with UST Requirements ENVl�N�WEN7 <br /> 'KkSii DEPAt3TIWENT <br /> FacilityName: Facility ID#: <br /> Facility Address: -7 E1' ReasoA fbr Submitting this Form(Check Orre) <br /> S Ch"geofDesignated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Des' ated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Natne(If differentfrom above): 4 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209)51$-4$36 ❑ Service Tcchnician X Third-Party <br /> International Code Council Certification#:$032295-LTC Expiration Date:06/11/2013 <br /> ALTERNATE 1 O banal <br /> .Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner 0 Operator a Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ 'third-Party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (optional) <br /> F <br /> ignated Operator's Name: Relation to UST.Facility(Check One) <br /> iness Nance(If dierentfrom above). d Owner ❑ Operator ❑ Employee <br /> ignated Operator's Phone#: ❑ Service Technician 0 Third-Party <br /> rnational Code Council Certification#: Expiration nate: <br /> T certify that, for the facility indicated at the top of this page,the iodividual(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 aim in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(please Print): f� <br /> SIGNATURE OF TANK OWNER: <br /> DATE: O'WNER'S PIHONE#: O � <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: www,waterboaTds,ca.gov/ust/eontaets/cepa aevs htrrtl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />