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41 'Ml� <br /> C.Em <br /> RECEIVr--, <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Regd %14 <br /> Facility Name:Ripon Shell Fac <br /> Facility Address: 341 E Main Street Reason for S (Chet ne) <br /> Ripon,CA.95366 Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PREWARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209)5184836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date: 3 'F i 7 <br /> ALTERNATE 1 liana[ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> LTERNATE 2 (Optional) <br /> esignated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Servic ird-Party <br /> NaYMNO !AN <br /> International Code Council Certification#: at . <br /> NVf <br /> I certify that,for the facility indicated at the top of thispage,the individuals listed ' 1 <br /> serve as Designated UST Operator(s). The individual(s)will co t <br /> facility inspections and annual facility employee training, in act o 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) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 07/18/13 OWNER'S PHONE#: S- ( O s- s <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/ust/contacts/cupa ag. shtml. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />