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0 0, <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Nam v <br />Facility M #: g0o <br />Facility Address:3y �, /yj,,VtV. G <br />s4v& . <br />Reason for Submitting this Form (Check One) <br />,4 Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone P 9f6 - O <br />Designated UST Operatorfsi for this Facility . <br />PRIMARV <br />Designated Operator's Alsace: L _, , e'. R i rn m O <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />Service Technician.. ❑ Third -Party <br />Business Name (ifaffm w tf -om above): A -F f a rd a. - -re -3 i° <br />Designated Operator's Phone#: (Z®9) rix ` ©( <br />Imernational Cade Council Certification # .� `I j (� ,. (f (� <br />Expiration Date: j 02 ' <br />Ai.TWRNATF t /nndama 1 <br />". !t♦ : w1 �.♦" ♦ :. 11 1. aRelation <br />to UST Facility (Chwk One) <br />f <br />■ Owner ■ Operator E Employee <br />9mviceTechnician El Third -Party <br />ji t u. � ♦. r u "/ . / � / �..... A + ....<.. <br />i #- 1 1 I ♦ t i {.. : .� ♦ w i.; 1 ' y. � <br />,✓II 1:1`t�f i ��� � '� <br />V D19M V ,, "p, <br />i': fir: , ! . ,, ; 1/ r. ■rInRelation <br />i. <br />to UST Facility (Chwk ♦ .' <br />■ Owner ■. Operator ■ Employee <br />ji t u. � ♦. r u "/ . / � / �..... A + ....<.. <br />1 7 ' 47TIM MM 11011 ♦ " ♦ i t i .1 . . ,. t t `. ; x. <br />1 1. • i; 1 t i . t t <br />NOTE: TM WCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO TMS <br />INFORMATION . MN 30 DAYS OF TH <br />I certify that, for the facility indicated at the tap 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, m 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) applicab and storage tanks. <br />L <br />NAME OF TANK OWNER (PI <br />SIGNATURE OF TANK O <br />DATE: 'S HONE #: <br />,1 <br />November 2004 <br />