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Jun 24 05 04:40p Aff -da-Test (209' 794-0112 p.6 <br />it.n 23 05 a5:02P Afforda-Test <br />NAM 17 OS 10c01A USTanx <br />(209) 794-0112 <br />5302603330 <br />owner statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compere vA'th UST Requirements <br />f-adb NOW <br />T�o•J 9�3�1a C NAP o: oee0WAd QpcWW <br />Fad Pr�Dee S9 9� O 7 1KC2 ries' 8aWasan om <br />pjSjgEMW usT Operatarlpl tgtt* Facift <br />PRWARv <br />OprWAM Nam= JANIN E Ktia;BY RM .0 o UST Fact *y (Chba one) <br />g,ainess Nana (1f dlrY�e.etfrpm a-omoT US'Taroc O oww O Enp"a a SerW a 7edrr�+ <br />O� od Opaolor+Pom 9: (63 1603849 O opwom m Tara Pany <br />bee"W60" Codi Corms Cal"Ca ion i. 92442244JC Fspir+ion ogre 16182=96 <br />ALTNRNATS I pOr►ienail <br />ipd ppeu4oc`s Name: RAINDALL KIMY rLdereo b UST rWaiiy (C�k �) <br />lame (V a"W M ft` mm"t U3T'am O owrr t7 EmONPI e a Sarvioa Tem <br />Phone 0 : (930) 260,11 O OparOrer ■ -mm FWfY <br />lerab+ror+sl cone c mmcmr eenpmien:e : 525059"C ExDraGon DaW t212 202 <br />MA - .,Te ! (grlena9 <br />Oeste Opegrers Nan= TERESA KIRBY Relation b UST Father tcbe&o �l <br />g Marna (Irdrle►ent bm rOore} U$TariX Q O o EMploy+e C Service Ted�eielre► <br />Oesgnstaa Opaatora p4oea s : (S3Q) 266 +T=4= O O+o* ■ Yt►bo Pamr <br />Inam2ama Coda Llaeral C4"Tcmbn a : 5244W -UC <br />6�irdtian l7®1e:1 tTt?31200i <br />ALTVMA1E 3 (0p6as9 <br />nelra Opersloe^e Name: Y LE 1 rielauon to U5T Feoft (Uieea anal <br />t)uw�eau NiamO (rrdiRaent hen aewep O O o Empteyee f Semite TecWician <br />Designated open tnx Phone e- .'''.Ori v- o �O z ooeralot O n iid r <br />rmmm atees Cowtt'R c"Oblo" 4 : Exv�a" Derr <br />a� <br />NQTE THE LOCAL ftm"TORY AGENCY NUST HE MMFWD OF ANY GHMQES TO r7= W-01W7110U <br />UT" 30 DAYS OF THE QIANGr L <br />l aertify that. for the tactility iMcated 3t the bop Ot dtis pfge, the individuals) %sled attws *M <br />solve as 0e:dgrm2 ed UST Opeamw(s). The in;!Mdual(s) wit conduct and doeurnard monthly <br />tacdity inspections and annual fau'ligv emplayes trainiM. in ac oordence with CAWmia Cede Of <br />Regummitum, tise 23. section 2715 (c) - M. <br />(ce with 11Mmquirt meets (stawses. <br />' FUrttterrnor'pr 1 nrtderstand attd ctrl In oompllan <br />meguations, and local ordinances) app%i=M* to underground storase tanks. <br />NAME OF TANK OWNER <br />OR OWNEIrS AGENT (Ploase Print) : 1------ J <br />SIGNATURE; OF TANK <br />OWNER OR OWWE" AGENT': <br />,.- OATS' <br />9 a OWNCWS PHON9 <br />P.3 <br />p.2 <br />T00®1 SHA07I 099C 66S 60Z IVA 100:0Z SOOZ/CZ/90 <br />