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11/10/2004 15:03 <br />209468343 <br />FIFTH FLOOR (b <br />PAGE 12 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name, <br />Facility Address, Facility ID #; <br />Reason for SubrniiLing this Form (Check One) <br />9 -Chan -V of Designated Operator <br />Facility Phor(c ft; Q Update CertificatcExpiration Date <br />PRIMARY <br />Designated Operator's Nam <br />Dwvv v&wmgA Relation to -UST Facility (Check Ong-) <br />Business Name (Pdifferentfrom above): <br />Designated Operator'sPhone M 0 Owner 0 Operator K Employee <br />73-1-S7019 13 Service Technician 0 Third -Parry <br />International Code Council Certification #: Expiration Date: <br />ALTERNATE I (Optional) <br />Designated Operator's Name: <br />Business Name (Ifdifferentfrom above): <br />Dc5ignaccd Operator's Phone <br />Tntcmational Code Council Certification #: <br />ALTERNATE 2 (Optional) <br />FDdS,snwed Operator's Name: <br />Business Nam- ff,"dirr­,I'— I <br />- <br />Relation to UST Facility (Check One) <br />IJ Owner 0 Operator 0 Employee <br />0 Service Technician 0 Third -party <br />Expiration Date: <br />Relation to UST facility (Check One) <br />11 m a oveJ, 0 Owner 0 Operator 0 Employcc, <br />Designated Operator's Phone #: 0 Service Technician 13 Third -Party <br />International Codc Council Certification #= Expiration Date_ <br />NOTE'THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OFT CHANGE. <br />regulations, and local ordiinances) applicable to underground storage tanks. <br />Af" i <br />. , 1� , "' , , <br />DATE: Z,/- OWNER'SPH®NCM -52/0-71.5—J-7do <br />r <br />September 2004 <br />A <br />