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Jun 23 09 05:42p Reliable PetroleumA 0 845-8953 p.2 11 Owner Statements of Designated Underground Storage Tank (ZIST) Operator -- and Understanding of and Compliance with UST Requirements Nlcility Name: . � y, - �- r;tc;lit} ;\ddns_ s:33L_.� t_f---�il;ly !r� l�'YLQ dt^ T�o Suhtnitting this FormFarilih Phone /t•-- C� � .._l =1 JE JpddLr t'ert;ficate I:xPiration Dale Designated UST t) I►ItIMaRY erator s for this Faciliily Designated Oprrttor's~' t , r_. _ Businesss -Name (f('ciiffrrc n� i`rnna of>r.,ae ). 0-09nated Operator's Phone H: Erternationa! C ode Council Certification u: .ALTS E I /O�tiiona_�r�_ Designated Operator*, Name: _Business Name (fftfJJJereni from above). Designated Openttor's Phone 4: International Code Council Certi tication 4 ALTERNATE 2 ( gall) Designated Operator's Name: Business e Uf'1i 'rr'�rl /rorr+ abiwe): DesignutLd Operators Phone P: [nternational Code Council C.'ertitic tt[ion t: Wil` l t/\Il n _tom. Relation to I:ST Facility (C'hcc:k Ones C t?wner ❑ Operator C Employee L�r-9a:n-� kLo Sen;cc rechnician ❑ Ihind-['arty Ftipiraiiott� I� )te: ______.�� (Rc;hition to 11ST F;teif;ty (Claruk Une) ❑ Owner ❑ C)pMtttn• C7 Ernployee ❑ Service Technician t7 'rhird-Party �� Expiration Date: Relation to UST Facility t'C heck One) ❑ Owner ❑ Operator ❑ Employee O Service Technician G Third -Party Fxpiration Date: f I certify that, for the facility indicated at the top of this pale, the individual(s) listed above wiI� serve as Designated UST Operator(s). The individual(s) will conduct and document rnone facility inspections and annual facility employee training, in accordance with California Cade of Regulations, title La. section 2715(c) - M. I Furthermore, I understand and am in compliance with therequirements regulations, and local ordinances) applicable to underground storage tankstatutes, NAME OF TANK OWNER (Please Print): I SIGNATURE OF TANK OWNERX i DATE: t - _ OWNER'S PHONE # NOTE: I) SUBMIT THIS CO.IIPLETED FORNI TO THE LOCAL AGENCY CNOT THE ST. TE WATER RESOURCES CONTROL BOARD) BY JANUARY I, 2W5. THE LOCAL .AGENCY LIST IS AVAILABLE 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHfN 30 DAYS OF THE CHANGE.