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0 <br />1 1,a 1+ 1 <br />but 71# :Ilk <br />-e ••: • e <br />I77.e .I:• • •:. o 111, <br />A+. •ae • .ie: I. <br />-: e : :a •e: : e <br />:i r.re13TIMPT <br />I:: <br />-:.c:e •: • rn � . <br />. c.a • I:: r; :•, �,: A � ..:,: : 1-r: : ,r :t. is - <br />•1' <br />but 71# :Ilk <br />-e ••: • e <br />I77.e .I:• • •:. o 111, <br />A+. •ae • .ie: I. <br />-: e : :a •e: : e <br />:i r.re13TIMPT <br />I:: <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br />Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br />and annual facility employee training, in accordance with California Code of Regulations, Title 23, <br />section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br />ordinances) applicable to underground storage tanks. <br />Z4 Signature of Tank Owner: <br />Date:—Ie' l lP _ 057 - <br />NOTE: <br />1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: <br />www.waterboards.ca.aov/ust/contacts/cula agys html <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 <br />DAYS OF THE CHANGE. <br />