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,S <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: I04RC 1 U t�S Facilily1D : <br /> Facility Address: i, ` Reason for Submitting this Form (check one) <br /> '3� � • U� 1 an El Change of Designated Operator <br /> t CIS Update Certificate Expiration Date <br /> LF:aj:ifijPhone : <br /> Designated UST Operator(s)for this Facility <br /> a <br /> Primary Cell Phone (209)-649-8956 <br /> Designated Operator's name: Dan Mcllrath Relation to UST Facility(check one) <br /> Business Name: Valley Under round Tank Monitoring ❑Owner ❑Operator ❑Employee <br /> Designated O erator's Phone 209 -475-0620 ❑ Service Technician [0 Third-party <br /> International Code Council Certification #:',5246558-UC Ex iration Date: 11/11/08 <br /> Alternate 1 <br /> Desi nated O erator's name: Relation to UST Facility(check one) <br /> Business Name: ❑Owner ®Operator DEmployee <br /> Designated Operator's Phone : ❑ Service Technician ❑ Third- a <br /> International Code Council Certification : JExpiration Date: <br /> Alternate 2 <br /> Designated Operator's name: Relation to UST Facility(check on�b� <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone : ❑ Service Technician ❑ Third-party <br /> International Code Council Certification Ex iration Date: <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br /> THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page,the individual(s) listed above will serve as <br /> Designatd 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, <br /> title 23, section 2715 (C) -(F). <br /> Furthermore, I understand and am in compliance with the requirements(statutes, regulations, <br /> and local ordinances)applicable to underground storage tanks. <br /> Name of Tank Owner <br /> or Owner's Agent(Please Print): <br /> Signature of Tank _ <br /> Owner or Owner's ssAggent: C <br /> Date: 22- z X11 t Owner's Phone#: `�lS�lk '� -I <br /> N <br />