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t)c <br /> owner Statements of Designated Underground Storage T (WT for <br /> and Understanding of and Compliance with UST Requlremen <br /> Facility Name: <br /> Facility ID#: <br /> Facility Address: 3 Reason Por S;;= ng Phis form(&A One) <br /> Jr- Change of Designated Operator <br /> X Update Certate B�piration Date <br /> Facility Phone# ® t) <br /> DWgnited UST O erater s for this FacgLty <br /> PRIMARY <br /> 12.Arnaliz Relation to UST Facility(Cheek One) <br /> Designated Operator`s Name:Karen <br /> Business Name(Ifdif'erent from above): o owner 0 operator © Employee <br /> Designated Operator's Phone#:(209)5184836 d Service Technician X Third-Party <br /> International Code Council Certification#_8032295-UC ExpirationlDate:06/11/20 ,3 <br /> ALTERNATE 1 tionat <br /> Desigaded Operator's Name Relation to UST Facility(Check One) <br /> Business Name(ifdif differentfrom above): ❑ Owner b Operator 0 Emptoyce <br /> Designated Operator's phone#' © Service Tccbmician 0 Third-party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 ( sal) <br /> Designated Operator's Name: Relation to UST Facility(Cheek Orae) <br /> Business Naive(If dif"erent f rom above); � Owner C] operator CJ Employee <br /> Designated Operator's phone#: 0Servict Technician O Third-Patty <br /> Tntesnationai Code Council Certification#: Expiration Date: <br /> T certify that,for the facility indicated at the top of this page,the individual(s)listed above dill. <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee txaining,in accordance with California Code of <br /> Regulations,title 23, section.2715(c)-(f). <br /> Furthermore,Y understand and am in compliance with the requirements(statutes, <br /> regulations,and local o anees) applicable to underground storage tanks. <br /> NAME Off'TANK OWNER(Please Print): d`�3 t- A' —T <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OV►NER'S PHONE q: e-d t� 5 E v <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESO1)RCES CONTROL BOARD)By JANUARY 1,2005.TIME LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.Ca. O'V/USt/contO S/CU a a s.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS iNFORNIATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />