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Owner Statements ofDesignated Undergroundria ' a Brat r <br /> and Understandingand Compliance ith UST Requirements <br /> Facility NlaNla r C 1 �� m acuity#: <br /> address ` � LLG7/� �L y Reasoai for ttyis farm: <br /> 1Faciiih°Tlaone# 0Change of Designated Operator <br /> �- _ 0 Update Certificate Expiration Date: <br /> C�)'09 /--Y-Lr2-----:3-96 <br /> D iiGNAXED UST OPEPLATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Y <br /> D.3ik�%ated Operator's Natrte � l.YLE D.NIMMO �~ Service'r,:eh--Beit+ <br /> Busir"Os Warne: �.p'�`ORP)A-T.E T t„ # 5249115-UC, <br /> a <L, <br /> Dr_;ignatcd Operator's Phonc 9: 44-0112) E.xpiraeion Date: 7r U"009 <br /> .,UTE: ATE 1 <br /> lie: grim=ev t Lrator's Name: � DAVID A.'VIN ERSy-n ice Teciav*tician <br /> Easiness A r FORDA-TEST ICC 4� 52624373-UC <br /> T"`gig-tared gperator's 1?axone Z:)9 74 -1)!1'L ira6oj Date 3i?7/1i)l_{3_ <br /> ALTERNATE 2 <br /> �Dt Jgnated Operaror's Name:� Z:ANE:A. 1vlls'111 O Service Technician <br /> Business MT ae: A FF'ORDAJUT 1CC# 5213)3322-LlC <br /> Desi.gr:ated Operatcr's Phone;#: 2-017744-0112 Expiration Gate: 3/14/22-011 0 <br /> ALTERNATE 3 <br /> Lyes;mated Operator's Name.: FELIX G.RAMIRE Z Service Technician. <br /> Business`Watne• AF ODA-TEST ICC# 527393)4-U6 <br /> Desig gated 0peratot's Phone 4: 4 209744-0112. � Expiration Date: 6/21/20 10 <br /> I certify that.for the facility indicated at the t.00 of this page,the individuals listed above will serve�s De.si&glat-d 1." T" <br /> Operet ors. The individuals will conduct and docu€ ent monthly facility irspectiona and annual facilit3-eir-Ttoyee training'in <br /> accordance with California Coxae spa Regulations,tie to 23,section 2715(c)-(f)_ <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and loo <br /> ordinances) applicable to underground sto: a tanks. <br /> NAME OF 7_AUNK t) d TL"'l➢ (P'rint): _ -- <br /> 1 <br /> SIGNATURE OF TANK ONVNER, <br /> DATE: _ �� �, ONVNER'S RHONE: <br /> t)SCf ,Mff n1ISCOMPLETEDFOR1M10'T HE 1t.,OCA[.AGENC`k(NOT STATE 1aVt TERS(LRU S SCO N' II R43 BOARD) <br /> AFT'ERStGNING "IHC LOCALAGENCYLISTIS.A.V LEAT: w.wat rT� s_ca ®4_'ttstlsxyttha�t9i 3a? tt� <br /> 21NO'O'flf—YTHE WCALAGENCY 01TANYCHANGESTOTHIS INMRMATIONW1"THIN30DAYSOF`%HECHA?siGE. <br />