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AUG 0 720 <br /> Owner Statements of Designated Underground Storage Tank(US'I�� ter ®9 <br /> and Understandingof and Compliance with UST Re uirent i"rt&`q co�Jjv <br /> P q of <br /> Facility Name: Facility ID#: <br /> Facility Address: RSZryj,�-6 *t, Reason for Submitting this Form(Check One) <br /> pjcoJ co -s, �j Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Designated USTrator+is for this Facility <br /> PRIMARY <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)518-4836 ❑ Service Technician X Third.:Pady <br /> International Code Council Certification#:8032295-UC Expiration Date:06/2012011 <br /> ALTERNATE 1 ® iional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (OQtfonal) <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): dtgRj9N S. D ti I Lio <br /> SIGNATURE OF TANK OWNER: ' '_-DUM I — <br /> DATE: ko 0 t OWNER'S PHONE#I: y IS:5 Cho d <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: w,,%-\t-.waterboards.ca.eov.!ust:contacts cupa ag_=ys.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 />