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0 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Fadlity'NFacility ID#' <br /> Facility Address: i Reason for Submitting This Forro(Check One) <br /> change ofDesigmted Operator <br /> Facility Phone V X update Certificate Expiration Date <br /> Desinated UST Operators)for thh:Facility <br /> Dempatcd Operator's Name:Kg ren R Arnaiz Relation to UST Facility(Check One) <br /> Business Nme(Ifdifferentfrom above): 0 Omer 0 Operator 0 .Employee <br /> Designated Operator's Phone#.-(209)5184836 0 Service Twbi&ian X Wrd�Party <br /> International code Council ccrtmcafion-#.8032295-UC F-xpimtionDdc:06111/2013 <br /> ALTERNATE I ftkonaO <br /> Designated Operator's Name; Relation to UST Facility(Check One) <br /> Business Name @-dffierentfrom above); a Owner 0 Operator 0 Employee <br /> Desigmed Opts toes Phone A: 0 Sm4cc Technician 0 Third-Party <br /> Code Comell,Certification W: Expiration Dae: <br /> ALTERNATE 2 (OpWa0) <br /> Designated Opewor's Mame: It to UST Facility(Chock One) <br /> Business Name(If&fferentfrom above): E3 OWner Q Operator 0 Employee <br /> Designated Operator's Phone#' 0 Service Technician 0 Third-Party <br /> Internshonal Code Council Certificadon 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 cnn&wt 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 under 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): 1; )/y4a 2HILWv <br /> SIGNATURE OF T OWNER: yl <br /> -1 F6 4 4 <br /> DATE: OWNERISPHONE M. 1201 SPIT <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGE <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL <br /> AT:w-ww.waterboards.ca.aov/ust/coiI him]. <br /> JUL 2 9 2011 <br /> 2)NOTIFY TIIE 1,OCAL AGENCY OF ANY CHANGES TO THIS INFORMATION VITMN 30 DAYS <br /> OF THE CHANGE. SAN JOAQUiN COUNTY <br /> ENVA(AMILNTAL <br /> HEALTH UEPNbT*hi&r 2004 <br />