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May 05 10 02:12p Reliable PetroleurnA 209-845-8953 p.2 <br />a 0 <br />a <br />Owner Statements Of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />FaCiIit`' -Address; <br />Phone N": <br />Irl <br />Fac ifity 1D z: <br />?th Reason for Submitting this Form (Cl2tei. osrc) <br />in CA 9,s? -,,G Changeof'Desisnuted Operator <br />p a 1z4. Update C ertilicae Expir;ttiott Date <br />Designated UST p erator s far this Facility <br />PRIMARY <br />J�si'geusW d Operu;or's Name: <br />0.t/'v1 RcJatiun to UST Facilih (Chark Qnal <br />Business IRatne {I)'diff rant front a6ovel_ Qa lam �.� _ . e /� -:- <br />Designated Operator's Phone <br />International Code Council Certification; e <br />Designated Operator's Name: <br />Business Name (1fdi1%rant fom aGove): <br />Designated Operatoes Phone m: <br />I'mLrAational Code Council Certification #: <br />ALTERNATE 2 (Optivnnd) <br />Designated Operator's Name: <br />Business Name 61f'ddfffel, ,,t from uLave): <br />Designated Operator's Phone ##: <br />International Code Council Certification #: <br />t!� en <br />Owner > >Jperator ° a Employae <br />r I( Service Techrici:ut Li Third -Party <br />%� (`, Expiration Date: !'L -L3 _ 1 - <br />Rc:Jntion to 't. -!ST Facilit} (Check One) <br />Q Owner ❑ Operator ® Employee <br />0 Service Technician ❑ Third -pa ty <br />Expiration Date: <br />Relation to UST Facility (C7teck C)rre/ <br />❑ 01"ner 0 Operator ❑ Employee <br />❑ Service Technician U Third -Pam, <br />Expiration Date: <br />I certify' that, for the facility indicated at the top of this page; the individual(s) listed abode will <br />serve as Designated UST Operator(s). The individual(s) wlIi conduct artd document monthly <br />facility inspections and annual facility employee training, in accordance vvith California Code of <br />Regulations, title 23, section .2715(c) - (fl - <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local Ordinances) applicable undergr nd storage tanks, <br />NAME OF TANK OWNER (Please Print): <br />SIGNATURE OF TANK OWNER: ' J01 I <br />I if r <br />OWNER'S PHONE 1+0 9) <br />A <br />ti®TE: I) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (: TOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY I, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />