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Owner StatementsDesignated •. .. • .. Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: See Table A <br />Facility ID #: See Table A <br />Facility Address: See Table A <br />Reason for Submitting this Form (Check One) <br />See Table A <br />® Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: <br />r - • -.• i • - •. •: <br />PRIMARY <br />Designated Operator's Name: See Table B <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (If different from above): See Table B <br />Designated Operator's Phone #: See Table B <br />International Code Council Certification #: 8014658 -UC <br />Expiration Date: See Table B <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: See Table B <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (If different from above): See Table B <br />Designated Operator's Phone #: See Table B <br />International Code Council Certification #: See Table B <br />Expiration Date: See Table B <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: See Table B <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (If different from above): See Table B <br />Designated Operator's Phone #: See Table B <br />International Code Council Certification #: See Table B <br />Expiration Date: See Table B <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br />Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br />and annual facility employee training, in accordance with California Code of Regulations, title 23, section <br />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 (Please Print): <br />SIGNATURE OF TANK OWNER: <br />DATE: z OWNER'S PHONE #: 7 14 3 <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 AT: <br />www.waterboards.ca.00v/ust/contacts/cupa agvs.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br />CHANGE. <br />November 2004 <br />