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Facility Name: %Tk-ii; <br />Facility ID #: j/ .DwAoell <br />Facility Address: l rJ �2 Ta <br />lA ej��7 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />®` Update Certificate Expiration Date <br />Facility Phone #: (2M) 410 3 _ G <br />Designated UST Operator(s) for this Facility <br />Designated Operator's Name: A44 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />fit( Service Technician ❑ Third -Party <br />Business Name (lfdierent from above): 450V <br />Designated Operator's Phone #: Vo 6) 4.37, ® bf 0 U., <br />International Code Council Certification #: -1 - <br />Expiration Date: Q Z -I <br />ALTERNATE l (Optional) <br />Designated Operator's Name: ;fm— <br />Relation to UST Facility (Check One) <br />W'Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (lf dierent from above): Uf5 <br />Designated Operator's Phone #: 1U) 5Q ! . 214 <br />International Code Council Certification #: * Z,'j _ L)C_ <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (if different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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 (Please <br />SIGNATURE OF TANK OWNER: <br />DATE: I " 0- - t l OWNER'S PHONE #: U13 ) n(o% - 4-t-6 <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 AVAILABLE <br />AT: w-ww_waterboards;cal;ov!ust/contactsicupa a s.html. <br />1 1 ! 1 II' , <br />OF <br />November 2004 <br />