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Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Fsfi I ityl�Me; Facility ID f: <br /> Facility Address: i r,u Reason for Submitting tris Form(Check One) <br /> �e <br /> rj,rb4-e.0 t Changa ofDesignated Operator <br /> Facility Phone ff X opdatc Certificate Expiration bate <br /> Designated UST OperatorLs)for thb lF$cility <br /> MflgARY <br /> Designated Opmtor*s Name:Karen R Arnaiz Mation to UST Facift(Check One) <br /> Business Name(Ifdifferentfrom above): 0 Ourner 13 Operator El RnTooynt <br /> Designated Operator's Phone#-(209)5184836 0 Service Technician X Third4larty <br /> International Code Council Ccifification 0.8032295-UC .expiration]Date:06111/2013 <br /> ALTERNATE I(Opd®nal) <br /> Designated Operator's Name; Relation to UST Facility(Check One) <br /> Business Name(IfdWerentfrom Above): 0 Owner 0 Operator 0 Employee <br /> DesignatedOp6mtoeg Phone#: 0 Service Technician 0 Third-Party <br /> #Intemat,orial <br /> ode Council <br /> .catificaflon W: Expiration Date, <br /> ALTERNATE 2 ft&od) <br /> ))eSignated opewor,s XWne, Relation to UST Pachiry(Check Oftq) <br /> Business Name(Ifdfferentfrom above)., 0 Owner 0 Operator 0 'Employee <br /> -5;i—p—aw Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Cooncil Certification 0-- piraiion Daw, <br /> I certify that,for the facility indkated at the top of this page,the individual(s)listed above will <br /> serve as Designated UST Operator(s). Tice individual(s)will conduct and document montbly <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 ordinaufts) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> SIG.NATURE OFT OWNER: <br /> r <br /> DATE: OWNER'S PHONE —442 SAE L, <br /> M, <br /> NOTE: 1)SUBMIT TMS COMPLETED FORM TO THE LOCAL ADEN <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL <br /> AT:www.waterboards.ca.00v/usYcoiltlaaLupa_agy&htM-I- <br /> JUL 2 9 2011 <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO TfUS XNFORKATION WITRIN 30 DAYS <br /> OF TIME;CffANGP-. SAN J0AC1Uiiq coUNTy <br /> EfiV;RQNMLNTAL <br /> HEitt-UH DEFWOREMr 2004 <br />