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V D <br /> Er--D <br /> tMAR 7 2008 <br /> ENVIRUNMENT HEALTH <br /> Owner Statements of Designated UndergroundTank( IT/SERVICES <br /> and Understanding of and Compliance S Requirements <br /> Facility Name: Pie. M;n i M,%TkT Fscil' IN: <br /> Facilitydr n.for Submittingthis Form (check ) <br /> 511 P r-% i s AV e Change of Designated Operator <br /> ')��K+Cfv Ca. QlJpdate Cerfficate Expiration Date <br /> Faci[LbL Phone#: O - `1 - %J12 <br /> Designated UST r(a}for this Facility <br /> Primary <br /> P22�qnated Op2ratoes name: Dan Mcorath Relation to UST Facility( ) <br /> Business Name;Valle U round Tank MOwner 00perator 0 Ern <br /> Op2rators Phone MR-M-649-8256 sarvft Technician Th' <br /> LIntemational Code Council Cerfiftation Ili: 5246558-UC ; nMIL4 <br /> i <br /> Designated Operatoes name: I Relation to UST Facility(check arke) <br /> Business Na 00perator OEmployde <br /> Designated OLtor'S Phone Service Technician 13 Third <br /> ,international Code Council Certification V Liagration Daft; <br /> Designated_ ratar's name: Relation to UST Facility(ch ) <br /> Business Name: Owner 170 r DEmployea <br /> s na O tor's Phone Service Technician 13 Thi <br /> Intemational Code Council Certification I Date: <br /> NOW L"- LCL REGULATORY AGENCY MUST BE NOTIFft Or AMY CHANGES <br /> THIS INFORMATION WITHIN 30 DAYSOF THE CHANGE. <br /> I oarlify that,for the fadI4 indicaWd at the hop of the Page,the individual(a)listed above will serve as <br /> Designald UST O r(s). The indivitluel(s)will conduct and document monthly llity inspections <br /> and annual fadlity atraining, in wwrdance with Cellfomia Code of Regulations. <br /> We 23,section 2715(C)-(F). <br /> Fa re,I understand and am In compliance with the requinmumts(statutes,Wgulatione, <br /> localand ordinances)applicable to underground stwage tan . <br /> Name of Tank Owner <br /> or Ownees Agent(Please Print): ' <br /> Signature of Tank <br /> Owner or er'SAgent: / <br /> Date- 4:)-49 Owners Phone V <br /> 4 <br />