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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: ;c -* 1,5'2— Facility ID#: <br /> Facility Address: /7 Z 3;0 C&,F,2 6 64A)4 Reason for Submitting this Form(Check One) <br /> k U d'i C1f 9, Z U e Change of Designated Operator <br /> Facility Phone#: v C�_ ( C ,5 ❑ Update Certificate Expiration Date <br /> Desh!nated UST Overator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: sok 41�,qchr Relation to UST Facility(Check One) <br /> Business Name(If different from above):WAL fe)A! �— i,1�:r 2i�1 rJc, ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: C//6- —�3.7Z—/F�� ❑ Service Technician B"'Third-Party <br /> International Code Council Certification#: S�� 4#gC17A c� CA:R Jas: Expiration Date: /Z, Z GLS E <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 <br /> OR OWNER'S AGENT(Please Print): i�«� //� �� � w' 1 ' -T iC, <br /> 1 <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 4.,� C, 2-7Z 66 It OWNER'S PHONE#: <br /> September 2004 <br />