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RECEIVE® <br /> I7NDERGRi UND STORAGE TANK SYSTEM <br /> r a OWNER STATEMENT 5 OF DESIGNATED I1'.;T OPERATOR AND JUL 2 4 2014 <br /> NI)ERSTANDING OF AN, D COMPLIANCE WITR LUST REQUIREMI N I'S <br /> 17 <br /> Pnr rrea hY Llnidor:.r Mem er�lgenciec orwher'a Aprrnvedby+r>itY ZucAl.7urlsdicliDrt ENVIRONMENTAL HEALTH <br /> AelhorlryCited, Tide J.Aiv. 3, Ch. 16Coliornia4Yrde"' RCgulUlioru(t.Y,'Rj^ J� M D 11 MENT <br /> FACILITY NAMT;i (qrl) C +11-S <br /> fry <br /> FACILrrY SITE OAESS Z ki U <br /> 'Z S A�2-r'is L-A-r7s�� �'"'s 1 — .•- - . <br /> Fl4iASON FOR SU'l7Mt'ITiN(i T'EP5 FORM{C'heck fora•): `. Char+@,e of Ucal�ah'd Operant r-i Update of JCC C.ercFficatiun F,spimdon Da[e{9) <br /> PRIMARY DTiSIG FATED UST OPERATQR, TOR <br /> .RATOR RIi1.ATIUN TU UST FACtI,tTY(Chark 0 ) <br /> DESIGNAT'E'D OPERATOR NAME: Jeramy CiUTI 'MinS . <br /> Ow <br /> N'. :2 Station Malii, ner [3 Operator [] N,mpluyx <br /> aUSINESS NAME(1fdlJferrnrlroruabnre7: BZ SBIna• © somico Technician Third-Pa{Y <br /> DESIGNATEDOFt�-'RaTGReFto'NF, (816)371-2: 8Q _ OW -_... sxrlRptTounATe:4/1 412 01 4 <br /> INTFUNATIONALCODFCUUNCR.C2IkTIFICA'riONN{ : $6'-9661•^ UC ., <br /> ALTERNATE 1 DESIGNATED U51'dIYERAT CODA'--�`'FACI-. { "u� RFjj PION TC.7 rUS1r F'ACILIT'Y(C/tock Qa) <br /> 1)EStUNATL•DOPr..RA70� �RN4AMC�: KelyiCruz T-��y,�, p Owmu. D Opornnr 0 Employee <br /> tA)SNESS NAME Uf r maw bf'O ow): SZ SEN' C6 StatlpFl lalnt., Inc, ..-- © Service Technician ® Third-Party <br /> DPSICiNATFSD OPERATOR PHONE: (J16) 371 t1$0 8._:�...^- •--_... — 1012$-�^12213 <br /> _ 8016282 UC ExPIRnIICN DAIT: <br /> INTERNATIONAL CARE COIINCII-CERTIFICATION N: .� ,-,•__. . <br /> ..._ALTERNATE 1 D_ESIGNAT_••„__E,)IJ5T QPF.R_A_7 3R IIY3Tt'S'HYu T'AG_�ITY�pp!h'.°o!) RELA'nON TU[ISI'FAC[LI'fY lCheck[7nel <br /> :9SIGNATED Uf'F:KAI'uR NAME—""^--'— <br /> James V'JII�: irt15 •,TQ Owr+et LNI-F� <br /> operator ❑ Employee <br /> " (;I ISN1'iSS NAFAt (IJd((Jeramfmm abavr!): SLr Ser.lice StdttUTl malnt , Inc �.. cc'I' ® Third-Party <br /> oLsir,NA'rrD Ol ERATOIC pHONr' (816)371-;:' 3$0 ext. <br /> 6252274 - UC �� 1't�^'�DN u 8/4/2015 <br /> RJr RNA77ONALU)DECAUNCIL CERTIFICATION- )�: ..... <br /> AL'l'12dtNATE 3 DESIGNATED UST OPERA OR FOR THIS FACILITY((l/rtinaeQ <br /> �_,,,^_,,,�_�._.- 12ELA'170N'TU U5l'FAClLTrS'(Check Otte) <br /> oFiSIUNA't'E➢p+9?RATO7t NAME: Rhot eDt:sbiens __ <br /> _ _ .., [] Owner © (operator ,Q�pI F..mPloyee <br /> nURINE55 NAME(tJ'd aredrfrnm abon:l: BZ Ser.AGO StatlOn Hllelnt., Inc .... O .S"C1v1CC TaulmiCim (pE Thud-Party <br /> MUG NATMOPERATUR PRONE: 916) .371- !3$0 _-�eX�_..-_.__..,. r I T.tO*i DAT>-2-07.2014 <br /> INTERNATIONAL CODE COUNCIL 0E1iTIFICATIO14 D.: 5244364-UC <br /> I certify that, for the facility indicated at to top of this page, the individttwi(s) listed above "til serve as Designated UST <br /> Operator(s). The individual(s) will eoudw and document monthly facility in.ptxtions and annual ore,I employee training <br /> in accordance with California Code of Reg' lationn,Title 23.Section Z71.5(c)throug ( tlrouuunderstand <br /> swenpdrn)ty°d am <br /> is cumptiaace with the ray <br /> nir•cmenta fstatut'� y regulations,Bud local ardtnaace;)applicable <br /> TANK OWNERNAME: ,._-.�-�ISIL�-'-i---(-�.4�,4...�'S`......._.'•"�."__..._..�r...�.�- -- <br /> OWNERPHONE: <br /> TANK OWN SR'rIT1,E: �� I f1 u Pa <br /> C <br /> TANK OWNER SIGNATURE: DATE:--.— <br /> .�,—.--�----.— '""" <br /> IN9'l`Yt 5 <br /> 1. Report the names)of the Dcsignatod US' OperKor(s)as registered with the ntem lional Code Council (ICC). ICC ccrtiflestion <br /> inforttation is available on-line at:www.il. �fe.org/e/cmrtsBurch html.Searci t'nr TS, Unido UST System Operators d <br /> �. Submit this completed form to the local agency that Mulates this facility'` l)STs, Unidocs memberCont agency jurisdictions and <br /> fist Y13. <br /> - cobmit information <br /> are listed on-![ne at www•unWocs.°t'gJmutabersfwh°regulateswhat•html. Contact information for ec <br /> uvailah at www.cwt'cb:ca.Cov/tltpltomehtst)aonwetsldocs/local agCncy_ <br /> 3, 23 CCA§2715(a)requires that you notify he local agency of any damages to xh is information within 30 days of the date of change, <br /> local agencies w d»n California is <br /> www.6mtdanu+re <br /> uN•o�-to <br />