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JUN 2 5 2009 <br />�i,�liOwner Statements of Designated Underground StE111RONhdIand Understanding ofand Compliance with UST' �iEALT <br />ft- Operator <br />Requirements <br />Facility * <br />L it <br />e n r Submitting <br />ul <br />o 10 <br />Facility - —A, —1d <br />1) llull- lity ID 4: <br />ress: 3 -3 u t - <br />A as() for Subm <br />s i t t i I I 7-1—F 0 r —mwil 1-1 <br />Change of Operator <br />Facility Phone #: <br />p at, <br />.C, <br />0 1 Jpdate Certificate Expiration Date <br />.YRI MARY Unerator(s for this Facilitv <br />Designated Operator's Name. <br />Relation to �UST Facility wbeck one) <br />Business Nam (/f.41re,cm <br />front above) <br />Designated Operator's Phone If: !20� <br />International Code Council Certification <br />ALTERNATE I LO tjonajj <br />Designated Operator's Name: <br />Business Name (iV'dy <br />.ferentfi-om <br />:aboDOperator's Phone 4 <br />loternational Code Council Certification #: <br />ALTERNATE (optional) <br />Designated Operator's Name: <br />Business Name <br />----- <br />Business Name above): <br />Designated ()perator's Phone #:- <br />international Code Council Certification 4: <br />,0 Owner <br />13 Operator 0 Employee <br />Service Technician 0 Ihird-Party <br />�-e4 —_n I 11— <br />Expiration Date: I � 71-1 <br />Relation to UST Facility (Check One) <br />0 Owner El Operator 0 Employee <br />0 Service Technician 0 Third -Party <br />Expiration Date: <br />Relation to UST Facility (('heck Ont) <br />• Owner 0 Operator 0 Employee <br />• Service Technician 0 Third-parv. <br />Expiration Date: <br />certify that, for the facility indicated at the top Of this page, the individuals.) listed above <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthlywill <br />facility inspections and annual facility employee <br />(f). yee training, in accordance with California Code of <br />Regulations, title 23, section 2715(c) <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 (Please Print):)( --) <br />DATE: <br />OWNER'S PHONE #: <br />---------- <br />NOTE: 1) SUBNTIT THIS CONIPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />A T: <br />2) NOTIFY THE LOCAL AGENCY' OF ANY CHANGES TO THIS INFORINTATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />im <br />