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Ei <br />DESiGNATED UNDERGROUND STORACA I AF7% A` <br />(800) 505-3588 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements. <br />ity, D-4: <br />Facility Name: <br />Submitted this <br />ReasonforSubm"i—Farm 4 -(Checks (ane <br />Facility Address'. 0 Change of Designated Operator <br />Update Certificate Expiration D+ <br />acilitv Phone #: Zo <br />Dej�w�nated�QST Oerator s�for IN, Iaci�il <br />PRIMARY ---7 Relation to 1.5-r Facility (Check One,,, <br />Designated Operator's Name', 0 Owner FkelOperator D EmPloYec.' <br />Business Name (if differentfrorr, above): 0 Senjice Technician -1 Third — Party <br />lintematianai Code Council Certifica tor. #• �'�Cj� "7 �dl (i �..�- � � --- <br />Designated Operator's Name: '� t�� � I Relation to UST Facility (Cheek Otte) <br />� Bc:siness Name (If different fre?m above): � p Service echnician ',� Thud -� °arty <br />Certificate Expiration D te: <br />Desigipmate!d Operator's Phone a2 <br />International Code Council Certificat0n <br />ALTERNAIE 2 LOPtionol)-7 <br />Designated Operator's Name., Relation to UST Facility (Check One) <br />Business Name (if different from above); El Owner El Operator 1— Employee 1 <br />i <br />J Service Technician —7 Third—Party I <br />Designated Operator's Phone #: Certificate Expiration Date: <br />International Code Cound! Certification <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br />THIS INFORMATION \,XIITH!N 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 />Designated UST Operator(s). The Individuals) will conduct and document monthly facility inspections and <br />annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) — <br />(f", <br />.--urthermore, I understand and am in compliance with the requirements (statutes, regulation, and <br />.ocal ordinances) applicable to underground storage tanks. <br />AAME OF TANJA-CXNI <br />WNER <br />11K OWNER'r'Acx�Or (Please Print); c), KALi <br />CXNATURE OF TANK------ <br />TVMER OR OWNER*1�,�'�GENT--) <br />DATE: OWNER'S PHONE: CZOq) <br />