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e9 i1 <br /> C' 2 9 2004 <br /> Owner Statements of Designated Underground Storage Tank (UST')'-prat <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: — (l 51�-6 ®3 le Facility ID#: <br /> Facility Address: 2 Z �- �,,7�,v � ,2 y� Reason for Submitting this Form(Check One) <br /> Cq [Change of Designated Operator <br /> Facility Phone#: 9-6 -1-14 16,-7 ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: SL; 41f0e6:e c:/ �'� ;{,G�7L S Relation to UST Facility(Check One) <br /> Business Name(If differentfromabove):WgZL,iA/ Dic, ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: c i/ —,3•72-- ❑ Service Technician Third-Party <br /> International Code Council Certification#: 5k, 41;1,gc1j q c1 C,r 4 kSs Expiration Date: (���L� �� /Z� Z(0 6 <br /> ALTERNATE 1(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 /> 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 OWNER /�� 11 <br /> OR OWNER'S AGENT(Please Print): /%i�«� /'�ry �y <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: , <br /> DATE: XJ C, 2 7, Z o'f OWNER'S PHONE#: �5'10— x'15-22-9S <br /> September 2004 <br />