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LJ <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: t2 <br />11-1,q �c� 7� 7 6 <br />Facility ID #: <br />Facility Address: 5c , <br />t5-4cl<-�LL"J <br />d L; v /�✓�= . <br />C/J `� Z/ 5 <br />Reason for Submitting this Form (Check One) <br />eChange of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: ;Z C -1 _ 22 - (, 3 <br />Designated UST Overator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Skk Affgo ,,'dC� R �� %�cR 7��= s <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician V"Third-Party <br />Business Name (Ifdierentfrom above): WqZ] e)Al %'AIC. <br />Designated Operator's Phone #: 9/E —372_ — <br />International Code Council Certification #: Ski 41t4C17. c/ Ck4 ks: <br />I Expiration Date: Oc ld kA; 2 /Z, Z c o C <br />ALTERNATE 1 (Ontionah <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE 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 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) applicable to underground storage tanks. <br />NAME OF TANK OWNER <br />OR OWNER'S AGENT (Please Print): �i/<,E-- A/4 n Vjz- Z6'; "' k sf°Io 41,, % ��C, <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: /14� C, 2-� ZCO1 OWNER'S PHONE #: <br />September 2004 <br />