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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />Facility ID #: <br />Facility Address: �� --�� ��„j� <br />ck /1) C Iq C� -S'Z-/ 7 <br />Reason for Submitting this Form (Check One) <br />eChange of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: '2 6®_ <br />Designated UST Operator(s) for this Facility <br />DDTMAI?V <br />Designated Operator's Name: Skk % #,g0hA � cc -,e <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Third -Party <br />Business Name (If d fferent from above): WjjgZ �d,l �- ia14 t 2iaf TALC. <br />Designated Operator's Phone #: c�,/E —,372- <br />International Code Council Certification #: 1= j &,?CJJ q cl CA:4;tr, <br />Expiration Date: ©c�e � 2 /Z, 2 C+D 6 <br />ALTERNATE 1 O tional <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. v <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 TANK OWNER <br />OR OWNER'S AGENT (Please Print): / %i�<k� �� �� ; /' '�' <-Jo/p <br />SIGNATURE OF TANK �/ ✓� <br />OWNER OR OWNER'S AGENT: <br />DATE: 4.0 c , 27, 661 OWNER'S PHONE #: �'/!�' �'i�' — 2 2 8's <br />September 2004 <br />