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!3/25/2009 20:37 2093394 7 LISA VERNENGO PAGE 04 <br />tNDERGRouND sToRAeE TANK. SYSTEM <br />OWNBP, STATENENTS ()F DESIGNATED CE WITH <br />LIST' OPERATOR AN]) <br />�� LiSTAI"')�u� <br />OF�1.'.Vi� �iOi�J�LIAu`� 1 LA hia Code �R&Vde0Qrw <br />I cartll+Y that, for tbs. f6cURYU dada t and dlocamelAt monthly hsililty io lape and ■nnUIRI IMMI y ®-V'-,7 .,...-. <br />Qpprator(g). The individual(t)1®tlAtslFf Talo 23, &emtlon �71s(c) through (f). �'urthe M0M ➢ understand and am <br />in accordance 'wKIs Cailforni■ Code Of RO tes, ra�t�latiatta, and loaak 27151 meea) applicable to gmdorgroatad starat a tanks. <br />in �mp8■hcp With the ragt►iroresnta <br />TANK 0M4FM NAME; <br />LANK C) WNER TML: -- <br />TANK SICIN A'T4RE; <br />M <br />C71)114--"tq <br />1. Report the namota} aftho Ac®igNted UST Op'4700r(a) ar rmglascsed atlth the internatvi& Cede a,7 W. ii (1CrC;). <br />2, <br />Submit thin ootnpleGed form the Yoke Count$ Envirotubant , H alth I)eop V�" tia . (S30) 6b4.1448 Cottonwood 6t,, Suitt 2400; <br />Woodland, CA 9 695, 'Via m mail; . chettgma to this infQrmetior� wiChf 30 clays of the date of ehem9e. <br />3, ;) CCk §171s(a) requires that ynu'ned1Y the local &&,maty of any <br />Z®/70 - Old 33N3NV11NVW ZU 090z:14 9T6 4S ;S1 oo iiyi— 5 <br />