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Jan 05 05 11:57a .2 <br />65vv 4u i2:.i$ rda 2 3� oii�ii t 11lR 1xY-Q1HKI1Ctr4Hl t tv Ui <br />Jan 05 OS f 3:16a <br />;.S. <br />Cal:`.F-nv-ircmencal S�w1ce� <br />Owner Sta..:-nunts of Jtesigtlated Underground Storage Tank (UST) Operator <br />and :aderstsndina, of and Compliance with UST Requirements <br />Fat,.iryNarnC ` ;;__.i: T J <br />Fat ity Addresa: <br />r,, z,1 s: / A <br />Fat i ity Phone C; - <br />,4 e S<< <br />tt)- "ty ID : <br />!, Reason fer Sob-Miay this Farm (Check 04e) <br />N : C� � Cht+o.=� of Aesigtta�.cd Operator <br />j[j� { ❑ Update Certificate Expiration Date <br />Desu%nated U'ST Onerator(Sl for this Facility <br />PR MARY <br />grwttd UDS° r� unc_ Thomas Lee Hj,ngston <br />Rciauno to i1STFaciIiry (ChecF Ong <br />C_=_ <br />j p, <br />.._. <br />1 C npc aror El Employee <br />I r7 Cur;cc Tceiui;aaa 10 Tltisd-Farcy <br />Ue _. ? <br />�: i % <br />E�pirai5on Dara: Q - �•'��6 <br />national Code C '' R Certi5t21ion J <br />At TRNATE 2 O "i'd +rt!) <br />Reierion w UST Facility (Gireak oma) <br />2,,aiedOpenwr, Mime: Gabr:ial. Urrea <br />Su o•", Nana (j J'FO <br />0 0 --II �eM17tOT ❑ );tnployce <br />De go.trd Opeasoi :•;'�SrtC m. 91 G-7272773 <br />a serricc T„c)micim q ihird-Party <br />[nt natiorul Code Ceni6etrion p: 62;�!�7y,�- <br />AI i"ATE Z <br />Rciation to UST FaciLN (Ch+r� One) <br />mich2al Kidd <br />Rir Hess Na+ne flTdi' v <.al riam oovvej: L • E • S . <br />0 OWnar R Operator D Employee <br />Dc mated Qperuor :: wnc �: 916-296/-2283 <br />i:] Service Tmimician 4 TkL� •Part)' <br />IAL nttional Code C,:: r '.i1 Ccufieationi 2 3 - L �C. <br />+iraaon Bim: <br />NMST BE NOTIFIED OF ANY CHANGES TO THIS <br />N( rE: THE LOC;: LL RE ;MATORY AGENCY <br />INWORM.' 11ON 8V1TEUN 30 DAYS C)F THE CHANGE. <br />I c: rtify that, fo: 'lir, facility indicated at the top of this pave, the individual(s) listed above will <br />SU, to as Design -t ] UST Operator(s). The individuai(s) will conduct and document monthly <br />fai . fity inspectir and annual facility employee training. in accordance with California Code of <br />RE rulations, rid' 23, section 2715(c) - (f). <br />Ft •thermore, I .L�uderstaad -,end am in compliance with the requirements (Statutes, <br />re ularions, au.. V.cai ordinances) applicable to underb onnd storafe t2nks. <br />N., KE OF TANK J'•VNER < <br />01 OWNER'S At. FAT (Please Print): C�C� <br />S14 NATURE OF' 'ji]vI+ <br />0\ NER OR OW' -;'t1'S AGEN - <br />Dj CE: OWNER'S PHONET: 02 �ff7 <br />Stprember_10t}1 <br />