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08/03/2011 12:18 209--957-3972 FEDEX OFFICE 5125 PAGE 02 <br />Owner Statements of Designated Underground Storage Tax k (UST) Operator <br />and Understanding of and Compliaace with, US'T.Requinm.ents <br />Paeillty Name:h rs-" IT radlity M ff; <br />Facility Add=zqgl Rc&qon for S jbinitting NsFom (check G* <br />ChanoMesignaW Operator <br />X Update Pcrtfflcate Expiration Date <br />DeshMaLted UST 0Pemto!*) for this Facill <br />Designated Operator's Namc-, Karen R Arnaiz Relation to V.;T <br />Facility (Check One) <br />13usincss Name (#'dqrerewfrom above): 0 Owner <br />3 Operator 0 Ernploycc <br />Designated Operator's Pt'0040#: (209) 518-4836 0 Service T�,hnician <br />X Third -Party <br />Tfftmational Code Council Cerlification ih $032295 -UC Expiration D*C; <br />06/11/2013 <br />---------- <br />ALTURNATE-1, (WonaA <br />I <br />Designated Operator's Narne, Relation to ViT <br />Facility (Check One) <br />Businems Name (If d6rerer#.TMH' above). 0 Owner <br />Operator 0 Employee <br />Designated Operator's Phone #: E01 Sncm�iceTLnician <br />0 Thir&Party <br />MAternationol Code Council Certification Expiration Date: <br />A.L RNATE 2 ffiWonaj) <br />Designated Operator'sName. Relation to Vi <br />T Facility (Check Ong) <br />Business Nomc (if dfffem. nrfMM above): 0 Owner 11 <br />Operator 0 E.Mployce <br />Designated Operator's Phone 0 Service T <br />hnician 0 MM -Party <br />International Code Council Certification Expiration Da <br />e: <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 individuallp) will coloduct and documentmonthly <br />facility hispections and annual facility employee traioga <br />in. accordance % th California i Code of <br />Regulations, title 23, scetion 2715(c) - (f). <br />I <br />Furthermore, I understand and am in compliance 10rith the requirementi (Statutes, <br />regulations, and local ordinances) applicable to on*rground storage tanks. <br />NAME OF TANK OWNER (Pleas <br />SIGNATURE OF TANK OWNER <br />DATE- j421 OWNER'S PHONE N: <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) By JANUARVII 2005. 10HP. LOCAL AGENCY LIST IS AVAILABLE <br />AT: W'ww.waterboard&g&gov/tist/contaqts/cu A agX&J, <br />tMI. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO! THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />