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4.pq - 4 1008 <br />*Wner Statements of Designated Underground Storage Tank (UST)Qpq4o�-,_- , <br />and Understanding of and Compliance with USTRequiremendE& <br />IVIT/SERvICE, <br />I ) ST 0 �O I I t I <br />Designated 0pemtor'sNamc. Koh- %f Relation to UST Facility (Check One) <br />Bushms Name (If&fferentfroin *bow): QkLiabI-c 91;1ter 13 Operator E3 Employee <br />Pcsipmd Operator's Phone#: t" (ooLf M Service Technician )< Third party <br />Intonational Code Council Certification #- <br />expiration C;) ot 0 <br />F�ifflA:iilr.VVMWf(,i7TriTTr,71Z <br />Reldion w UST Facility (CAwok 0,�) <br />0 Owner 0 Operator Cl E Mployet <br />El Servic�Tcchnimn 13 Thixd-Paxty <br />I W" ,1.- <br />aTIIQT �,w <br />Change of Desipated Opetator <br />0 Update Cortificate Expirwon Date <br />I ) ST 0 �O I I t I <br />Designated 0pemtor'sNamc. Koh- %f Relation to UST Facility (Check One) <br />Bushms Name (If&fferentfroin *bow): QkLiabI-c 91;1ter 13 Operator E3 Employee <br />Pcsipmd Operator's Phone#: t" (ooLf M Service Technician )< Third party <br />Intonational Code Council Certification #- <br />expiration C;) ot 0 <br />F�ifflA:iilr.VVMWf(,i7TriTTr,71Z <br />Furthermore, I u7ife-i-talid 5171ji &,T <br />DATE: 0VMR1SPU0NF1#-. <br />2� NOTIFY TH6 <br />Reldion w UST Facility (CAwok 0,�) <br />0 Owner 0 Operator Cl E Mployet <br />El Servic�Tcchnimn 13 Thixd-Paxty <br />BuSinto Name (VW(ffirerafrom abow): <br />J.-itavrMl * =I- <br />. . . . . . . . . . <br />Furthermore, I u7ife-i-talid 5171ji &,T <br />DATE: 0VMR1SPU0NF1#-. <br />2� NOTIFY TH6 <br />Relation to UST Facility (Check One) <br />E3 Owlier 0 Operator 0 Finploym <br />13 ScrviceTaftician o nird-Party <br />BuSinto Name (VW(ffirerafrom abow): <br />nir,77 =77mi—.7�1710M <br />. . . . . . . . . . <br />Furthermore, I u7ife-i-talid 5171ji &,T <br />DATE: 0VMR1SPU0NF1#-. <br />2� NOTIFY TH6 <br />