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RECOVED <br /> MAY 2 4 2005 <br /> Owner S at egttt%f Designated Underground Storage Tar>�I� H <br /> jt*1 A'�Z i7nders�nding of and Compliance with UST Req 1 <br /> couN <br /> Facifig NT Facility ID#: <br /> Facility 3 �,,>I , C G-(�,�.fl/-' Reason for Submitting this Form(Check One) <br /> -1-�-�1 S-'Change of Designated Operator <br /> Facility Phone#: Ro ti Lt t6 ❑ Update Certificate Expiration Date <br /> Designated UST Oaerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Chuck(fill Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above):CHAMPION PRECISION TESTING INC ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916927-1557 ® ServiceTechnician ❑ Third-Party <br /> International Code Council Certification#: 5250259-UC Expiration Date: 12/17/06 <br /> ALTERNATE 1 liana! <br /> Designated Operator's Name: Ed Stearns Relation to UST Facility(Check One) <br /> Business Name(Ifdrf/erent from above): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916927-1557 ® Service Technician ❑ Tbird-Party <br /> International Code Council Certification#: 5450492-UC Expiration Date: 12/128/06 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:ALVIN MU BURN Relation to UST Facility(Check One) <br /> Business Name(Ifdi$ereni from above): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916927-1557 ® Service Technician ❑ Third-Party <br /> International Code Council Certification#: 0878949-UC Expiration Date: 12/15/06 <br /> I certify that, for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): i` ,— <br /> SIGNATURE OF TANKOWNER: / p <br /> DATE: 2 ,� —2 (y t5.5 OWNER'S PHONE#: <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:Atzstr.waterboards.ca.gov/ust/contacts/cuna aevs.htinL <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />