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Feb 2211 12:49p _ <br /> p:J., <br /> WlaUN ERGR U4TMKK SYSTEM spy 2 11 <br /> OWNER STATEMENTS OF DESIGNATED JUST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE W�TFT UST REQUMMENTSoutv(Y <br /> For use by Unidocs.NemberAgencies or where approved Try your Laoal Jurisdiction `a'L'`JTAL <br /> AuAoriryCited: Title 23,Div, 3, Ch. 16CaltforniaConi-ooegulatioms(CCR) AHT,NEfJi <br /> FACILITY NAME rACIGTI';PHONE <br /> fex x'09 333_600c> <br /> irACaM Sri L ADDRESS r Ci1"Y - <br /> REASON FOR SUBMIT7'NO THIS FORM(Check one): Change of Drrignuted Operator J•❑Update of ICC Certif:eatlon Expiration llate(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIONATED OPERATOR NAME: JaMeS VViliaMS RELATION TO UST FACILITY(Cheek One) <br /> BUSINESS NAME(ijd0nntjradabow): BZ Service Station Maint., Inc. ❑ Owner ❑ Operator ❑ Emp'.oyte <br /> DESIGNATED OPERATOR PHONE: (916) 371-2380 cXt. ❑ Service Yetlnii pian � Third-?arty <br /> I TERNATION.ALCODE CCUNCIL CERTIFICATION NO.: 52552274-UC EXPIRATIONDATE: _ 12-22-2012 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(O Monet) <br /> DESIGNATED OPERATOR NAME: Ed Stearns - RELATION TO UST FACILITY(Check One) <br /> BUSNESSNAMr(7jdljSmnrjranebase)t BZ Service Station Malnt., Inc. ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATEDOPERATORPHONE: (916) 371-2380 "xt. ❑ Service Technician ® Third-Party <br /> N71:RNATIONAL CODE COUNCIL CERTIFICATION NO.: 52504.92 UC EXPIRATIOtt DA]'E: 12.22..2012 <br /> ALTERNATE:DESIGNATED UST OPERATOR FOR THIS FACILITY rDpri,pnnlJ <br /> DESIGNATED OPERATOR NAME: Stan Yoder RELATION IU UST FACILITY.^.hack,One) <br /> BUSINESS NAME(trdlffaren:fan abate): BZ Service Station Malnt., Inc i❑ Owner ❑ Operator ❑ Employte <br /> DESIGNATEDOPL•RATORPHONE: ' ❑ Ser.•ies Technic(an ® Third-Part)• <br /> (916) 371-23$0 ext. <br /> N7'ERNAYIONr1L CO1 COUNCIL CERTiFICAT10N N0;. 5250317-UC —� EXPIRATION D.AT°: 12-155-2012 <br /> ALTERNATE 3 DIi.RGNA'1 L'Il UNI UPERA'I'UR P'UR I t3IS FACILITY(vyn na() <br /> DESIGNATED OPERATOR NAME: Rhorre Uest)iens RELATION TOUST F.ACIWYY(ChetkOne) <br /> BUSINESS NANmr wd& nrfrom cbovej: BZ Service Station Malnt,, Inc Q Owner ❑ operator ❑ Employee <br /> DESIGNATBDOPERATOR PHONE: (916) 371-2380 0"T. ❑ Service Technician Third-Party <br /> iNTERNATIONAL CODE COUNCu C[RnFICATION NO.! 5244364-UC EXPIRATI NDATE: 1/2/2012 <br /> I certify that, for Ute facility indicated at the top of this page, The individu I(s) listed above will serve as Designated UST <br /> Operatur(s). The individuai(s) will conduct and document monthly facility in�upeetions and annual facility employee training <br /> in accordance with California Cade of Regulations,Title 23, Section 2715(c) t�rough (Q. Furthermore, I uadcrstand and am <br /> in compliance with the requirements(statutes, regulations,and local ordinanceF) applicable to underground storage tanks. <br /> TANK OWNER NAME; <br /> T'ANKOWNERTITLE: QFt��f�9C_ _ OWNER PHONE: <br /> TANK OWNER SIGNATURE: DATE: �iiJ�( <br /> INSTRUCTIONS <br /> 1. Report the name(s) of the Designated UST Cperator(s) as registered with the I(ttemational Code Council (ICC)- ICC canif5canon <br /> information is available on-line at; www,iccsafe.org/cicertsearch.html. Search ror"California US7-System Operators: <br /> 2, Submit thu completed forth to the local agency that regulates this facility's JUSTs. Unidocs member agency jurisdictions and <br /> contact information are listed online ut: www.unidoeLorg/memberslwhoreulateswhat.html. Contact information for Other <br /> local agencies within Califomia is available ac riww.awreb.ca.nov/ewphometu�UcontacWdocsllucat_a gency_Nut.xL,. <br /> 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to th4 information widtin 30 days of the date of change. <br /> UN-06?-1/1 nYv�.'-unldoCY.ol'� <br />