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1' 010 10:59 2093671796 BILL'S #0817 P. 002/002 <br /> owner Staements of Desipated UndaVvund SwMe T (TS'l)Opwgor <br /> wd jjndentanding of wd comphanm with UST Requhements <br /> Fatuity Name:BILL'S 76 FOOTIty m� <br /> gam Ad&v= 633 E(ACTOR RD Reamn for Sd=ktwg#w Foy one) <br /> LODL CA 9-TM p CknW afDcsW=d <br /> FwMy Phonc#: X <br /> _U0wCAjtMcawExpkafim Daft <br /> Paksafed UST s for thb EMI-ft <br /> PRD"Ry <br /> s to UST Fa hW(awA 0'w) <br /> Busies (IJ fmm )- Lw p owner ® OPCM&W n Fmpwyee, <br /> ,s #: 1, X SaTica T <br /> hdcmSfiong Code CouEwff Catfficatiam#: -ITC ENphzfim Dag=IWSZM12 <br /> ALTERNATE I <br /> Dedpaftd s Name. Retahm <br /> to UST Fsadity(Oigck OW) <br /> { Q owner ® operamor n Empirj= <br /> s Piyo�e#: ❑ Savi=Todmitim n <br /> haennemd cope COOD&C=f0cafim s_ <br /> ALTERNATE 2 { <br /> peri s Name- Rdatm to UST Facfldy( ) <br /> Busb=Nae(1}'& above): [7 Oww n Opmkw n Fmployee <br /> s #: o Seraioe T - - 0 Thi <br /> hftmtjaW Code Camcff Caffwafim#: Date: <br /> I certify that,for the&ffity indicated at f of this s)fisted above wM <br /> serve as Designaftd UST r(s),. 'lee j (s)vigi conduct wd docatnent monWY <br /> facility'mspechons wd amug facility cEaployee tzamm&in with of <br /> Regulations,tine 23,section 27I5(c)-(I). <br /> I <br /> regulifiens,and local <br /> ard' )applimble <br /> `3 ( � storage tanks. <br /> NAME OFT O ): tJ ! t I�+l <br /> SIGNATURE OF TANK 0WNM-A!�, LLL�e- <br /> DATJL* <br /> I)SuaMrr TMS COMPLVM FORM TO THE LOCAL A SPATE WATER <br /> }RCESCONTIML By jAMARy 4 2w&TM ImCAL.AGENCY Uff IS AVAILABLE <br /> AT:www.watcrboards.ca.Z-oviust./conw�M�*/C-.u.i),a. aAys.h»"L <br /> 2)NOMY THE AL AGENCY OF ANY CHANGES TO THM DWMUTMN WMIM 30 DAYS <br /> OF THE CKANGF- <br /> November <br /> 2004 <br />