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Jan. 10. 2005 8:40AM W t Star Environmental, Inc. - No, 8333 P. 2 <br /> Owner Statements of Designated Underground Storage T r (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nate: C, y Facility 1p <br /> Facility Address_ <br /> 10Q1-1 (1 © L Reason for Submitting this Foam(Check One) <br /> CA �JJ ❑ Change of Designated operator <br /> Facility Phone#: o <br /> ❑ Update Certificate Expiration Date <br /> Resignated UST Q erator s for this 1r aei <br /> PRIMARY <br /> Designated Opea7for's Name:' B~5T 1Vt*-%MerN{r Rotation to UST Facility.(Check One) <br /> Business Name(If di ferext from above); <br /> Designated OpCsatoi's phone#: ® Owtur ❑ bpeTatOY p Employee <br /> J9"21����$ p D Service Technician 'Ibis$-parry <br /> Intamational Code Council Certification 6- .1, -7Fxpiration <br /> ALURNATE 1( sal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> BUM=Name(If diferest fjnm abaVe): <br /> ❑ Owner ❑ operator Q Employee <br /> besigaated Operator's Phone#: ❑ ServiceTechnician' G This-Party . <br /> International Code Couna7 Certification#:' Expiration bate: <br /> ALTERNATE 2 (opdondll <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name Qf di,jierent from above): <br /> ❑ 'Owner d opeaator R Employee <br /> Designated Operator°s Phone# 0 Service Technician d Third.- <br /> party <br /> International Code Council Certification#: D <br /> I Expiration <br /> aw <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST IBE NOTMW OFNGES TO <br /> INFORMATION 30 DAYS OF CHANGE. <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 employte 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 <br /> requirements <br /> regulations,and local ordinances)applicable to underground ' <br /> NAME OF TANX OWNER <br /> -OR OWNER'S AGENT(please print): 2S_3_C <br /> SIGNATURE OF TANK <br /> «ve iVt1tC C.1 vVIiI °�AC�.i✓!�"I': <br /> DATE: 1�`l-�o� OWNER'S PHONE#: a qc a 1g CA <br /> Septetnber 2004 <br />