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Pei tw <br /> Owner Statements jrslgnaW Undergroxmd Stcww <br /> jo of Ce with USI <br /> Facility Nw=- N1 CL -.5 76 FSGNY 0#: <br /> Rem=for Sasnkft this Form(Chok One <br /> Facility Addres: (tou,s,4&) <br /> k Ic. a Chmw of DcApiokd Openaor <br /> -%> Ko CA Q x It q <br /> Facility Ph=f ('2 aA 1—Q3 d, 0 update cardfiede Expi=ficn Dde <br /> Me-64MMd MT 92MAREM WE <br /> P <br /> Deggnmed opustoes Neum AL VIN MLBURN Rebbon to UST Facft(Check One) <br /> Zi <br /> Busnes Name(VAp7vwfmwaboPq): CM4UF10NPRWLS10XTEMkVINC. o Q)%Vm 0 Employee <br /> Do4naled Opwake$PhOw#: 651-353-7 0 Service Technicim n TkmVP=ty <br /> afim 9-UC <br /> ExpiradonDate- 1215108 <br /> Ittemaficnal Code Camcil Cedffic #: OW/994 <br /> ALTERNATE I(Offldm* <br /> Deskgulted opmew$)bme: Toj=8mM Rehhou to UST Fad*(Ckec*One) <br /> Busmem Nwne(Vdjffer4*fmwabavet: CMWION PRECAW0N1MMINC. Ig Owner El Operator E3 Employee <br /> Des*naW Opu*es ft"M 661--%3-74M El serviceTcChniam a Twr&pwty <br /> IntanaflojW Coft Cousca Celfificafim M 52=33-UC E*afion Dalm. 811"9 <br /> AMIMNAT92 <br /> DMpded0per4fte0buh- Ed Stesus Relsfion to UST Facfty(Chec*One) <br /> Busiw=Nw=(,YJffWMtfrM4b0w)-- cz&jjM0NPAWISMTES7MAC- a Owner 13 Operatar .E3 Employee <br /> 13 0 SarriwTOchuidw Thbd-Pmty <br /> De8*M*�dqpavWqFkvw#.- 661-36-1-W <br /> hjuudi0ndC0&C0uncHCatMcafi=#: 54 92- Fxpitafim Datm. 128M <br /> ALTEMATE37 (Op"44 <br /> DedguAed0puuWsN== RenWdBdd&.k RdWon to Un Fmffi*(Che&0M) <br /> Busme=Name(yd&r~fivm abm):0j4AfiWN PP.W&M TESTM MC n Owner (3 Opad" E3 Employee <br /> Deggaded OpuuWs Pbme#:661353- E3 SaTim T 0 Thk&Psrty <br /> hftTnefimd Code Comcd Cafificefim 5256869,-M Expkadon We:307109 <br /> I cerfify thet,for the fimirity• dicalbed.at the top of thu Page,the i8dwidu4s)Wed above will <br /> .,,.as,Designated UST Operator(s). The indiViduAKS)WiH Conduct and dMM3eM mnt* <br /> facility ins��Md annual facility .qq0yW Mmog M wwr&ww with California Code of <br /> Reguhtions,fitle 23, section 2715(c)-(Q.: J. <br /> FuI MdWd"d a2d SO iR COMPHSOM With ae n4wreneaft(Statutm <br /> repLsfieus,MW WCd OWbMKM)MIPPk"W uu&rffewW sterqp hudu- <br /> NAM OF TANK OWNER 4%we PCW)-' <br /> siGmATuRz Or TANK OWNER: <br /> DATE-. leliX IZ-&-o 7 OWNE"pHopM#.. 2,) 4 7 6 <br /> TMC6MrjzMr0M TOTHE hOWCAL (NOT TRE STATE WATER <br /> Non.1) i <br /> RISOURCES COMMOL BOARD)BY JANUARY 1,2m Tm LOCAL AGENCY Lwr is AvAH-ABLE AT: <br /> wwwwaterlya,wds.ca.gov/usttwnto;wqup-a—agvshtnd. MORMATION wjjHN 30 DAYS OF THE <br /> il-46-Tffiii-iwi LOCAL AG19NCY OF ANY CHANGES TO TIM I <br />