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er Statements <br />oloesignated Undergound Storage #nk (UST) Operator <br />and Understanding of and Compliance wi-th UST Requirements <br />Ib <br />FbIcility rr r ) tr i <br />�Rason <br />For Subm h <br />is Form <br />0 Change of Designated Operatorc: <br />Designated it <br />PRIMARY <br />#'LReLSt 1r r <br />differeni <br />Owneroperator e ♦ t <br />yee <br />L1 Service y ,.... 19 Third-P!rq <br />.. .•, , : . i ,,. <br />ATF' • <br />Relation ♦ UST Facility (Check <br />1. , <br />■ Scroice■ Third -Party <br />� i r <br />L*sir 1 Or s 1 <br />IWO una ificMion <br />❑ operator ❑ Employee <br />....... - .. , <br />Expiration 13ate: - <br />Relation to UST Facilely (C Or) -- <br />- i e,' ® Operator ❑ F l ce 1 <br />oy , <br />, <br />lEx iration Date_ <br />I certify tbat. for the facility indicated at the top Of i page, i <br />listed above wiI'. <br />serve as Desigmted UST Operator(s). The m-dividual(s) will conduct / .fcwment mnthly <br />Regulations, accordanceiCO i. o , <br />1 <br />Furthermore, <br />i 1 and am in compliamce <br />regulations,i local ordiujmce-q) <br />NAME OF TANK OWNER (Pies.. <br />I = - <br />SIGNATURE <br />OF <br />J <br />NOTE: 1) SURAVIT THIS COMPLCTID FORM!(NOT THE STATE WATER <br />RESOURCES I BOARD) >i <br />AVAILABLE AT. www,w'?k14z!:boards.ca.goytp, <br />2) NOTIFY THE LOCALAGENCY OF ANY CHANGES TO THIS INFORMATION <br />0 DAYS <br />OF THE CHANCE. <br />