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Owner Statemeats of Designated Underground Storage Tank (UST)Operator <br /> and Understanding of and.Complianco with UST Regeairemcnts <br /> ao ty Addrossr g��� IN^ �/� Rauon for Subtniuiug this Form(Check One) <br /> G q,�5&7(o rhnngc of D04Sna10d 0Pcrat0e <br /> Vacility)?hoar#; p d /o o Updaso CtttifiooDo F.ZcPirationDasa <br /> 1pesiggated VsT Operator(for this Facility <br /> PRIMARY <br /> D pperst es Name: 0,44,P—APA-1 rix.i�vs Relation to UST Far4W(Check One) <br /> $trsiaeas Nr�s(Ifdi�ere+rt m aboves)i lC7f/>u4�it1Y/EC t:/ 0 Owns' 0 Operator o Employee <br /> Designated Ooorutvr's Phaaa 0: 4// O Sctvloa Teohnician fid'Thir�P�Cty <br /> jnwnwiiond Co&Council Cor001don#: .56PJ45 ce,?6 "a C FacpirationD�s: <br /> AI,TIRNATE><L09 Lia_aaV <br /> Ii <br /> .L+,^aNaaw: otutiaa to UST Fewilely(Check One) <br /> T}wi,�tad Ope+ <br /> BusinessNone(Ifdt•farantfirmabovg): ❑ Owner 0 Operator ❑ Employee <br /> Dooig�mcl Opocmtoc'o Phoma*: p scr ice Teobaiolan d Tbjrd4 ty <br /> Lgernadonal Coda Council ccr ficadon#: Expiration,Data: <br /> 'A'LligNATE 2 (OptimaD <br /> Daaignat+cd Opctalat' <br /> s Name. Relation to UST Facility(Check One) <br /> Busitvoca Name(Ifd irrsAr from ai�aW{): ® Owner ❑ OPa a Or . ❑ EoQ 10Yce <br /> p s s Phono X Q 5twvice Teobriclau ❑ Third-)FOM <br /> luwrnational Code Council C=Mcation Expiration Dace: <br /> NOTE:THE LOCAL RE6ULATO12Y AGENCY 1. UST)3E NOTIF3D OF ANY CHANGES TO TMS <br /> INFORMATION WlTffM 30 DAYS OF THE CB ANGE. <br /> I certify that.for the facility indicated at the top of this page,the Individual(S)listed above will <br /> serve as Designated UST Oisemtor(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee traWag, in accordance with Califon is Code of <br /> Regulations,title 23,section 2715(c)-(f). <br /> Furtherwom,T understand and unit it compliaace.with the requirements(statntea;, <br /> regub,4Wns,and local ordinances)applkable to underground storage tanks.. <br /> NA-m 'OV TANK OWNIZA <br /> OR.OWNW S AGENT'VUtue Print): N��H �-- <br /> sIGNATURB 00 TANK �1� <br /> o••Aq=OR QVC"S AGENT; <br /> DATH; 1. - Z-O�1 Ow1 XWS 1 01E 0: <br /> Scptcttlbar 2004 <br /> C0012 "r0- .� r <br /> T9 39tid 3Aa3SAIMA Z90ZZE869Z b9 :ZZ 000Z/LZ/ZT <br />