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_ _ .. <br /> UNDEIRGR( UND STORAGE TANK SYSTEM <br /> IS[ ary <br /> •� ;;,, OWNER STATEMENT OF DESIGNATED 1.1:4T OPERATOR AND <br /> UNDERSTANDING OF AA:D COMPLIANCE WITR UST REQUIREMENTS <br /> Pw use by tircrdocs Mem er A,Renc&m ar where approved by i our I ocal.lurl-ldidion <br /> Authority Cited.' Title '3,Div. 3,Ch. 16 Cali miaCode Ragulalfav((XV <br /> FACaITYNaMFi � MLILWY I'1 (1NE....--_,...— <br /> _ Q N y L L'rN t, <br /> FACIt,frY 51'T6^6A 'pR'ES—S �— PITY T <br /> L"p-D I—..� -_�1 5-2- U7 !? <br /> REASON FOR SUBIN1TiWG 1105 FORM(Chrck Dar): Chrmgc of Ocslga4tcd Opczator -r�i Update oCICC Gerti6ratioa F.xpi.nttiUn Ua[CSsJ <br /> PRIMARY DESIGNATED UST OPERATOR YOR THIS FACILI'CY _ <br /> DESiailixao OPERATOR NAM,NR Jeramy Curl'mins Rr-BtLnT7UN'1'D UST FAC•a.ITY(Cksrk(J") <br /> allSME.s4NAMEtUJtjfarreclrau above): BZ Sery, � Station Mal11t, Inc. ,-- ❑ owner F] Operatoc 0 Bmpluya <br /> DEYICxNA'fEA?OPtiRATOR PNO'NG: <br /> (918)971-2:$0 a%L 0 Scrvica Tcchniuian ® Third-vary <br /> _ 8018— - C sxPlRn'nounnTeT 4/14/2014 <br /> WTERNArlONA4 CO0ECOONCR.C4° TIFICA110NN1 <br /> ALTERNATE I DESIGNATED UST 0?19RAT' )it'EM�CHiS�- _S FACI&-ffY{Omc9.0 � .fION TO USr YAca19'Y(Cin ckCiacJ <br /> llBS1GNATaD OPERATOR NAME: Kelvin CN�� ._ . <br /> ^--------- p Owa�r. Q OPamor ❑ EnIpluyse <br /> Al1SWESS NAME Itfd((kaatJroxrubuw+J: BZ$CrY ;s Station Maint., I17C. ._ QServiea Technician (( ThiM-Petry <br /> GaiSIfiNAT6D OPERATOR PHONE, (91 6)371-i:380 l!!n. _... <br /> 8016282 UC E cPIRA'non DD'ni>: 10128!2013 <br /> iw,m(NxTIONAU COAD IE UNCII-CERTIflu T70N N' .: ---^-- <br /> :AL7'ExNATE DESIGNATED UST OPERA't OR i�OR�i�OR PHTa^PAGD.ITY laD ""ol) RE[.A'nuNr0 usT rAciirrYlcaerku>n.) <br /> 'f iiSIt74ATF.D OI'F.RA R.NAME: JaMeS Wilt Ims �•. �—,-�,. . cmur Employee I <br /> 171ISIN'SS NAMB(ffd♦deNmf"mat�): BZSenlce Station Maint�lno �.. Snrvloe Tcwnniuian 1� Third-party <br /> pEsiGcvA1r:DO7'ERAiw<p}ttIw: (816)371-% 380 • B/41..01 <br /> 6252274 UC - ] [' T(UN DATE: ? 5 <br /> WTI7RNAT10NAL CODE COUNCIL CkiR'rlptCA7'10Mf 1 .... <br /> AL'CERNATB 3 DESIGNATED UST, R' OR FOR THIS RACIJLtTY( +?t,+•'�+aU RE7,A170th TO UST FAC1LIfY(Che <br /> DFS1UNn'rED OPERATOR NANIE� {2hOR12 DE:iib!®nS _ U Uperator © yee <br /> aUSWE.4S NAME(If djJerearfrnmabon! feS "ICC 4utatlon Meint., inC Owner Part <br /> SIXv1W TeuliniCiva tryy <br /> DESIGNAT&D UYERATUR PISONP.: (91�7) 371- .380 ext ---- .---- --73Z--i—x:0-7-201;4 <br /> 5244364-UC r'.xP71tAT1oN <br /> UffERNATIONA[.CODE COUNGiL C61t77F!(:ATION D --�._�, --�-- <br /> certify that for We facWty iadicatad at alltop u1'chis page, the iadividudiO listed above will serve as <br /> I Designated UST <br /> Operator(s). "Phi:individual($)will coaduei and document monthly facility iniptxtnuns umf annual facility employee training <br /> naire <br /> nd <br /> in accordance with California Code <br /> ,Startlon <br /> und <br /> �{ S' ;1LA�1�tions,Title'sai= 'S.`_'......-- d am <br /> is comPViaoce with aha rmywota � , rtgulatioaSad local ordiaaarcO APPiark to underground staLm mi <br /> TANKOWN6RNANE: <br /> TANKOWNERTITIX: <br /> OWNERMONE: ,C4 LS <br /> �! C DATE:_.^.^ C l 4 <br /> TANK OWNER SIGNATURE: _. - <br /> fN�R�5 <br /> I. Report the nems($)of the Dtstgnat©d I.JS Operstor(s)as registered with the n4e rarivnal Code Council(ICC). ICC cerliFicat on <br /> urisdfctioas and <br /> Utfucmation is available on-line at www.t. safe org/u/eortsutrch html.Searcy for"Caiifumi t UST'Sysuot(Jpereto <br /> ?. Submit this completul Faun to the local agency that regulates this fael]ity'! 115Ps, (iaidocs member a(,ency j <br /> l agency <br /> sumacs ills Maple are IisSad nn^Ilraa nl www.cnida:s.argJ>setaberslwhuregltlateswhath[1a1. Contact u7fl ,aAnat for ocher <br /> tnation <br /> onencWdoLs/ <br /> local agencies widiin Calirorttia is Vailab he <br /> !WW a-envy -c any ab uses w dt 4 inFotraat nn w thtuaa30 days of the date of change. <br /> 3, 23 CCR§2715(x)requires y vy IMS <br /> www.urtidncMrit <br /> UNas±-fn <br />