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May.02.2017 10:36 PM W terloo Liquors 2094614114 PAGE. 6/ 6 <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 <br /> of 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 Print): <br /> e4ltA C,1n &4- <br /> w <br /> SIGNATURE OF TANK OWNER- <br /> -#Jj-0 - <br /> DATE:— jg�,, I. OWNER'S PHONE#: Z-0'7 &-ik.. ly <br /> MAY 0 S' 2017 <br /> EVVRONMEWAL HMTH <br /> PEMMIT/SERAr.E3 <br /> November 2004 <br />