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RECOVED <br /> JAN 1 205 <br /> T <br /> Owner Statements of Designated Underground Storage Tank (UST�=490EHEALTH <br /> WCES <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 1-5 shtk Gasolim 64-4tvw Facility lD#: Pan d;14 <br /> Facility Address: '717 W4 18-M Sf4­S+0Ck_h1/CAq52o66 Reason for Submitting this Form(Check One) <br /> 0 Change of Designated Operator <br /> Facility Phone#: 2oq- 3qa-0,764 R Update Certificate Expiration Date <br /> Desiggated UST QMrator(s)for this FaggLq <br /> PRIMARY <br /> Designated Operator's Name: qds Relation to UST Facility(Check One) <br /> Business Name(If difirerentfrom above): TKt cvnsalb'A Ina 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 2-o9- 60 1-70 419 - 0 Service Technician W-Third-Party <br /> International Code Council Certification#: S2e- aTCIC-W Expiration Date: Q o6 <br /> ALTERNATE 1(OpfionaO <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification ff: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(IfdiffereWfiwn above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <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 OFT OWNER(Please Print): J 0 E ­0 A IU a--T PIA 1\,J <br /> SIGNATUREOWNER: <br /> DATE: 0 107 0 S OWNER'S PHO N�M- <br /> f a 4Eco- 2- <br /> NOTE: 1)SUBMlT 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 <br /> AT: <br /> 2)NOT THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />