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Nov 29 07 12:42p <br />erre <br />Afforda Test <br />9 <br />(209) 744-0116 <br />0 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator. <br />and Understanding of and Compliance with UST Requirements <br />ity NE -.' _ � .. M ,. Facility ID k <br />ity AMmss• / � A , ,,� - (Q Reason for Submitting thin Foran (C•heck One) <br />i c3 5 `F' Coo,)4 r C f Lt lar. J � �11 "' )4 Change of Desigaated Operator <br />ity Phone �F: . _ to - ��`j ❑ Update Certi iicatc Fxpiration Date <br />Designated UST Uperator(s) for this Fatcili <br />PRIMARY <br />Designated Operator's Names L.K° - <br />� 1 f7't E7 . � Relation to UST Facility (C:fur:k One) <br />Busi nem Name (ifdifferernf rm V.- - _"{meg �- ❑ OW►!gC . t] Operatnr ❑ Employee <br />Designated Operator's Phonq' ;� Servicc'rcchnician O 'third -Party <br />Internatiotud Code Council cx►tio ►j (l + L) G Expiration Datc: (jam Oi DLr' <br />ALTP,,RNAT>J i <br />Designated to N —zA ReMon to UST Facility (Chock One) <br />Mi e ( fro/Td utwvc): , � _ ❑ Owner 0 Operator ❑ Employee <br />_ hone to., -74 `/ 1 Service Technician O Thud -party <br />Int stt nlv Council Certi ation�v�3 Expiration Dat.- <br />ALTE TV, 2 (•._.•..-, .. <br />Z.Mig4d era A:V 0 Relation to UST Facility (Chock One) <br />Kusinem Na ff front above). _ n Owner ❑ Operatnr D Employee <br />Designated O to hone If_ � .1 1K Scrvice'reeimician o Third -parry <br />Interttstionai C Council Corte tion 7-15 -7,-6, _ Expiration Date: ajaZ <br />NOTE: THE LOCAL*U TOIL AC, CY MINT S1E NOTMMD OF ANY CHANGES TO THIS <br />INFO,RMAT O I 1N 30AYS OF THE CHANGE. <br />1 certify that, for the fAlity indicated at the top of this page, the individual(s) listed above will <br />serve as Designated US'11:' Operator(.,;). The individual(s) will conduct and document monthly <br />facility inspections and annual facility cmplayee training, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (t). <br />Furthertnore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAM O F'I'ANIK OWNER (Please Print.): <br />SIGNATURE OF TANK OWNER: f7�L� %' • "J _ r� r} r <br />DATH,: �"� } OWNER'S PHONE 1h <br />NovemIxir 2004 <br />