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,Mar 26 07 11:40a Forda Test 81 744-0116 p.1 <br />Owner Statements of Designated .Underground Storage Tank (LIST) Operator <br />and Understanding of and Compliance with UST Requirements <br />lityNirne: Facility w it: -A� O 3 - <br />lity Addtcas: Reason for Submitting this Form (Check One) <br />rN&,^-1tccQ.(,4)4 Change orDesignated operator <br />lite Phone 4: 4 11_ P 171 --1 Z - r -I Lok ❑ Update Certificate Expiration pate <br />1Desip-nat _UST OAerator(s) for this Facia <br />PRIMARY 1 <br />Designated Operator's Nam C �. 4• Relation to UST Facility (Check One) <br />Business Nam- (ifdoerenl frnm ab-cw A f f d rdo.- - -re S'i- O owner o Operator ❑ Employ" <br />DesiVxdcd operator's Phone #- SeMoo Technician yO Thfrd-Party <br />International Code Council Certificadon #: � '7 �, n(piration nate: <br />Designated operator's Name: ^'Zt PIS- Q . R % VVkM0_ <br />Relation to UST Facility (Check One) <br />Busiums Nam (IfdiffPreiufrom above.): C .a - <br />13 Owner ❑ Operator ❑ Employee <br />Desigraatod operator's Phone # fps j -7 <br />Service Technician O Tbiord-Pmtiy <br />International Code Council Certification N��(p�� � <br />Expiration Dote: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name; <br />Relation to UST racility (Chcak One) <br />Business Flame (Ifditwnt from abow), <br />❑ Owner 0 Operator 0 Employee <br />Designated Operator a Phone fl: <br />�( service Technician ❑ Third -Party <br />International Code Council Certification It: <br />Expiration Date: <br />NOTE: THE (LOCAL REGULATORY ACI,NCY MUST BE NOTIFIED OF ANY CHANGES TO TFIIS <br />INFORMATION WITHIN 30 DAYS OF THE CUANGIE. <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 employcc,training, in accordance with California Codc of <br />Regulations, title 23, section 2715(c) - (t). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tatoks. <br />NAME OF TANK OWNER (Please Print) - <br />SIGNATURE OF TANK OWNElt: <br />DATE. `��' �" ®� OWNER'S 1"HONE #: �1 - - � 11 <br />i <br />Novcmbc,.-t 2004 <br />