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SAN J0 i,,QUIN COUNTY Owner Statements of Designated Underground Stor s p rator and Understanding of and Compliance with Requirements Facility Name: al�Ile_ JQ Facility ID #: Facility Address: , Ln 7C,04 C4 Reason for Submitting this Form (Check One) lb Change of Designated Operator ❑ Update Certificate Expiration Date Facility Phone #: 3 Desisnated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: B r u c e N. H o a g l a n d Relation to UST Facility (Check One) Business Name (1f different from aboveT.e c h 1 a n d T e s t i n g, I n r ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone #: Z U 9 — 7 2 4 — 9 4 2 0 91 Service Technician ❑ Third -Party International Code Council Certification #:5 2 4 6 9 3 2- U C^ Expiration Date: 11-19 — 2 0 0 6 ALTERNATE 1 O bona! Designated Operator's Name: K e v i n M -a t 10 c k Relation to UST Facility (Check One) Business Name (If different from above) --f a� 1 a n d I e s t i n I n ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone #:2 0 9— 7 2 4— 9 4 2 0 M Service Technician ❑ Third -Party International Code Council Certification: i069874—UC Expiration Date: 0 8 —18 — 2 0 0 6 AT.TFRNATF 2 /Dntinnatl Designated Operator's Name: Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Business Name (If d fferent from above): Designated Operator's Phone #: international Code Council Certification #: Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please Print): iK�X II II L%I 411A n LV,/gadL r SIGNATURE OF TANK OWNER: DATE: / (, l �' —DSK— OWNER'S PHONE #:..20 5 ;2 39 — L/ 7 !�� NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/cupa agys.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004