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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: See Table A Facility ID#:See Table A <br /> Facility Address: See Table A Reason for Submitting this Form (Check One) <br /> See Table A <br /> ® Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: See Table B Relation to UST Facility(Check One) <br /> Business Name(If different from above):See Table B ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: See Table B ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 8014658-UC Expiration Date: See Table B <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: See Table B Relation to UST Facility(Check One) <br /> Business Name(If different from above):See Table B ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:See Table B ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:See Table B Expiration Date:See Table B <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:See Table B Relation to UST Facility(Check One) <br /> Business Name(If different from above):See Table B ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:See Table B ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:See Table B Expiration Date:See Table B <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br /> Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, title 23, section <br /> 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 Print): g", �, IAF E <br /> , �t- �cs�� .,_ -_fi_ Ce apeCi ISt <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: 3 <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 AT: <br /> www.waterboards.ca.gov/ust/contacts/culla agys.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />