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to <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Req uirem".,, <br /> F-Acility WIM. aA 6,W S16 <br /> Fadfity ID <br /> Reason-for SUbtfiftfing.d&Form(G%eck one)' <br /> IM a=VofDeApated0p.Ww <br /> flacitiV Phone#: 13 fJp*ft Catiflem E*mjon Mft <br /> Rg_inated <br /> N101"y <br /> D*pftd OP=Ws Nam: -Greg Kalftr Rotation to UST Facility(Check Oft) <br /> Busincu Name W40drenifiom above). Kober Commerebi Petrajonm 0 Owner 13 Opentor C3 ftpjoy= <br /> Designated OPWRWs Phone#: (M)BB7-209 13 Service Teftician 0 Tbim&Party <br /> International Cade CowwR CwffwWw#, 5232319 Expkation Daw. W17/20117 <br /> AL ATB I(OM*n4a <br /> DeeWaW OpetOW's Name; ftpliasio Mar"y Relation to usr Fawity(Check one) <br /> Bushm Alwo(Ydfro*abovq).- Jcaiw Comm"tW petrojeem 13 Owner C1 Opmtor a FAV10yec <br /> Designated Opwatoes Phone 0: (X9)U74M El Service TefticianCom email inn#: 0 Thim-pany <br /> Eagp N 1 <br /> A.LTUMTE 2 Lopamd <br /> DcWpftd OpttaWs Name. f2j PS&A Rotation to UST Fledity(Cimok one) <br /> Bu-,ftm Nme(ffd&mntfrom above): 0 Owner 0 Openstor E3 Employee <br /> Daignated e Phow 14 -ZLe.- 7q I t Saviceleduxician 0 Twr&?wiy <br /> Intemationd Co&Council C=Idficatiott R(004 Exphvdon Daw.j?-1-0 - <br /> I cerfify dMt,for tW facility indicated at the top of ft$page,the individual(s)fistedve will <br /> saw as Designated UST Operator(s). The individual(s)Will conduct and document monthly <br /> ftifity insmoons and annual hcj- <br /> .bty employee Uainihg,in' <br /> Caffo <br /> am <br /> Re ons,title 23,section 2715(c)-(f). rdance rnia Co&of <br /> Furthermore,I understand and am in Compliance with the reqWremauts(sWutes, <br /> r%ulations,and to ordiumces)applicable to underground storage <br /> NAME OF TANK OWNER(Pionse Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE- _R-1j,17 OWNERS PHONE q zS-7 0 <br /> NOTE:1)MMM THIS COWLETED FOM To THE LOCAL AC <br /> ,,F,qCy(NOT nM STA TE WATER <br /> RESOURCES:CONTROLB I OA.RD)BY JANUARY 1,200&THE LOCAL AG16WCY LIST IS AY IK <br /> 2)NCWIFY THR LOCAL AGENCY OF ANY CHANGES TO TIIIS INFORMATION WVrHW 30 DAYS <br /> OF THE CHANGE. <br /> Nov mber 2004 <br />