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�. <br /> UG 072009 <br /> Owner Statements of Designated Underground Storage Tank(USIA,"for <br /> and Understanding of and Compliance with UST Require $ <br /> r �w �'qC <br /> FacilityName: Facility ID#: <br /> Facility Address: rM 6 �t Reason for Submitting this Form(Check One) <br /> mcoq�cco, Sr�� Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Designated UST Uiueratorfs for this Facility <br /> PIUAL&MY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 51$-4836 ❑ Service Technician X Thir&Party <br /> international Code Council Certification#:8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATE 1 LOpgmal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If&fferent from above): ❑ Owner ❑ Operator CJ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <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 /> 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(Please Print): 19 D o.. <br /> 1 <br /> SIGNATURE/ l✓OF TANK OWNER: J <br /> DATE: t OWNER's PHONE#: a 01 U5 NOCb � <br /> r <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: ti+-,%-\%,-, 'aterboards.ca. vl�ust:contacts cu a a�zcs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> T •d <br />