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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Facility ID Facility Address: Reason for Submitting this Form (Check One) Facility Phone Change of Designated Operator Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator’s Name: Relation to UST Facility (Check One) Business Name (If different from above): Designated Operator’s Phone Owner Operator Employee Service Technician Third-Party International Code Council Certification Expiration Date: ALTERNATE 1 (Optional) Designated Operator’s Name: Relation to UST Facility (Check One) Business Name (If different from above): Designated Operator’s Phone Owner Operator Employee Service Technician Third-Party International Code Council Certification Expiration Date: ALTERNATE 2 (Optional) Designated Operator’s Name: Relation to UST Facility (Check One) Business Name (If different from above): Designated Operator’s Phone Owner Operator Employee Service Technician Third-Party International Code Council Certification Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document facility inspections and annual facility employee training, in accordance with California Code of Regulations, Title 23, Section 2715(c) - Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER OR OWNER’S AGENT (Please Print): SIGNATURE OF TANK OWNER OR OWNER’S AGENT: November 2004 DATE: OWNER’S PHONE