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Owner Statements#DesignatedUndergi-ound Storajfank (UST) Operator <br />and Understanding of and Complifince with USTRequirements <br />Facifi—14. tyName: C -4 -AMI Facility ID #: <br />-SiA - gihis,Form _0 for Submittin(Check <br />Fault Address <br />q - <br />Rgignated UST Operator(s) for this.Facility <br />PRIMARY <br />Business Nam (ff di <br />ff <br />.f!�,Ttfir�om above): <br />0 scrAce Technician W Third -party <br />I DcsiwWpd Operator's Phone <br />---t-anirat-i-o-n- -D-atem-1 <br />I <br />ALTERNATE 1WtaW <br />I <br />Desi mated Overator's Nam.:�=Relation to UST Facility (Check One)—j <br />Business Nam from abo-ve): <br />d ce Technician 3 Thi A -Part <br />y — <br />ici.-.mor's Phone #: <br />I LIX071=1_1 <br />Designawd s Narne: <br />o owner o operator r3 Finployee <br />13 ServioeTediniCian E3 'rhird-Party <br />I)esivated operator's Phone----- <br />g*pj!A!ion Dge: <br />I ca* that, for the &cffity indicated at the top of t1is page, the individual(s) listed above win <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />faciWy jnspections and annual fwlhty employee tranung, in accordance with Caffornia Code of <br />Regulations, title 23, section <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 />SIGNATURE OF TANK OWNER: C- k <br />DATE: a% 2: - H OWNER'S PHONE L <br />NOTE: 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 <br />AVAILABLE AT: m"-.waterbo. rdsxa.&Qx/—us1/c"t <br />NOTIFY THE LOCAL AGENCY OFANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />TF THE CHANGE. ANI <br />