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Dec 28 04 12: 00p Rur Sibley - Sr. HSE Co 7072-8947 p. 3 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Facility Name: 3 $ (p Facility ID#: 15 581 (p <br /> Facility Address: ,�/� Reason for Submitting this Form(Check One) <br /> 34/ E I�'1tulm-J oa- X Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> eLT zuv�vtolV�+,e1J7C�cUsvc r 0S <br /> Business Name(IfdiQerentfrom above): Owner Q Operator 0 Employee <br /> Designated Operator's Phone#: —gp t S—SoLS 0 Service Technician X Third-Party <br /> International Code Council Certification#:U vq L,t Prtss,.v Expiration Date:tie T I"pL 116 LE- <br /> ALTERNATE 1 ffl /I `,(e D <br /> Designated Operator's Name YZ k>-5 Relation to UST Facility(Check One) <br /> Businm Name I di ereni om above): f l Suc O Owner ❑ Operator Q Employee <br /> Designated Operator's Phone#: _ c i,- D$ 7 Ll ❑ Service Technician X Third-Party <br /> International Code Council Certification y - U L Expiration Date: ej ,Z 2.0 O <br /> ALTERNATE LOIgEnA <br /> Designated Operator's Name: A,k e V A PLA Relation to UST Facility(Check One) <br /> Business Name(IfdiQeL <br /> rentfromabove): DCTr� z`uv,now.�,e✓rnc c�sJc vOwner ❑ Operator ❑ Employee <br /> ❑ <br /> Designated Operator's Phone#: 630- 6 0---037 ❑ Service Technician X Third-Party <br /> International Code Council Certification cl ( � L Expiration Date: 6 )-C o C <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 Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) -(f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances)applica le to underground storage tanks. <br /> NAME OF TANK OWNER(Please PriZZIACU <br /> v A- 54L)J &e-- <br /> SIGNATURE <br /> OF TANK OWNER: �C <br /> DATE: OWNER'S PHONE#: q//a-,2 �� <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2015.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.m�atcrboards.ca.jzov/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> 1,i....a..a....,)nna <br />