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LLF� i VI <br /> E VIROM,MtrN T HEALTH <br /> VaES <br /> Owner Statements of Designated Underground Storage Tan0AMAerator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Facility Address: —t Reason for Submitting this Form(Check One) <br /> rc ❑ Change of Designated Operator <br /> Facility Phone#: 6-o---2."7 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator J ,Employee <br /> Designated Operator's Phone#: 3863161 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: 7 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: , r Relation to UST Facility(Check One) <br /> ,, <br /> Business Name(If different from above): ❑ Owner 11 Operator •❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: ! _ �- Expiration Date: -f>eerZ <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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 OWNERk. <br /> OR OWNER'S AGENT(Please Print): ( C- o <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 1 �, 1 1 OWNER'S PHONE#: <br /> September 2004 <br />