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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 />Facility Name: t- de, S )VJ.�Z kL�: 4r1,1q <br />Facility ID #: <br />Facility Address: 7 Z 7 Z tip s-�- ,-,q,JIz- <br />ISSN c, -k- F C c .5' Z d <br />Reason for Submitting this Form (Check One) <br />eChange of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: :2- 6 9 _ `�, Z- - 8-9V 2- <br />Designated UST Ouerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: �, A#,och" c% <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Third -Party <br />Business Name (Ifdiferentfromabove): <br />Designated Operator's Phone #: q j - �3,72 - <br />International Code Council Certification #: .5,e t J�f�iaCd7� c7( ��R1`�: <br />Expiration Date: IZ, ZCo C <br />ALTERNATE 1 (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 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 /1 <br />OR OWNER'S AGENT (Please Print): / %i�«� /) ��y, Z0'; &',' k S¢0I0 1144 <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: s <br />DATE: / c, 2 -, Z, 601 OWNER'S PHONE #: <br />September 2004 <br />