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Fab 221112;49p P•1 <br /> JAY ci 20i <br /> 9f �� SYSTEM�� 1 <br /> OWNER STATEMENTS OF ESIGNATEIII UST OPERATORAND <br /> UNDERSTANDING OF AND CO LIANCE Vj11TH UST REQUIREMENTS <br /> For r'.te by Unrdacs,Member RgerrNs or wherdapprt 06yyour Local Jurisdiction <br /> AtahorityQled: 7rfic2J,Div.3, h. 16Cdl�!brniaCjjdrrorRegalarlons (CCR) <br /> FACILITY NAME FACILkrY PHONE <br /> FACLI- Ys11BADDAESS CITY <br /> REASON FOR SUBMrrITNO THLS FORM(Check One): LJC1=l;*alDt�g=cd0pcmmrj U Update of JCC Certiftmioa Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR <br /> THIS FACILITY <br /> DESItiMATED OPaftATORNMdF- JaFrses VV; <br /> llafnsfRELATION 70.ST FACILITY(Clretk Ow) <br /> BUSINESS NAME(rfd�imar,ron ai-a J: BZ Service StatiO Maint, Inc, El Osmcr ❑ Operatw ❑ Emp'.uyet <br /> DES[^uNATGO OPi:aATOR PHONE: (916) 371-2380 col. � ❑ Service TUI1r11cien 7ltird.?� <br /> iNTERNAt'1OV-4LCODB COUNCIL CERTIFICATION NO.: 5252 4-UC EXPIRATION DATE; 12.22-2412 <br /> ALTERNATi I DESIGNATED UST OPI✓RATOR FOR Tf IS PACILITWO ripnat) <br /> DESIGNATED OPERATOR N?.ME Ed Stearns RELATION TO UST FACILITY(Cheek One) <br /> BUSISMS NAME(/Je,7a.entjrc,o aLc 4: BZ Service Statlor Maint., Inc. ' ❑ Owner ❑ Operamr ❑ Catploycc <br /> -DEWMATEDOPERATORPHONs: (916) 371-2380 ext. ,� ❑ ser+•ice recnnidan 0 Third-Parry <br /> M]'tRNAT10NAI.CODE LVLNCLL CSRTfFICATION T•IO.: 52504 2 LC ExplR.i'fONDATE: 12-22_2012 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY f0prionny <br /> 01710LUA7ED OPERATOR NAME: Stan Yoder . RELATION TO UST FACILITY(Cucl Om) <br /> SUSI1411�!,'S NAME(Z(dlfermrfrdvt obwa): BZ Service Stador Ma nt.. Inc 1 0 Otma ❑ Operaror ❑ Employee <br /> OLSJGNATEDOPEKKPORPEONE: (916) 371-2380 ext. ❑ Stn•iea 7cchnicion ® Third-Fan)• <br /> INTERNA'rIONALCODECOUNC(LC_RTIFICATMN'NO.: 52503 ].AJCEXPLLZnT[ON DAIS: 12_15_2012 <br /> ALTERNATE 3 DESIGNATED LSR <br /> T OPERATOR FOT S FACILITY mpripnalJ <br /> DESIGNATHD OPERATOR NAME: Rhome Qeablen-S RFJ.ATION YO US'r F.ACIIITY(Check One) <br /> nUSINMWAMF(ff;;i•+enr=—h-w): BZ Service Station Maint., Inc ❑ Owocr ❑ Operator ❑ Employ., <br /> DESIGNATL•'I)OPERATOR PHONE: (916)371-2380 axY, ❑ Scrvice Technician Third-Part., <br /> IN'rERNATrfINAL CODE f:OUNGLCEATtFiGnTION NO.: EXPIRATION DATE: <br /> 52443 UC 112/2012 <br /> I certify that, for the facility indicated al the top of this Page, the indhyidu�i(s) fisted above will serve as Designartd UST <br /> OParmur(s). Thr irdividusi(s) will conduct and document monthly faciliry Jn4pettions and annual fseility employee tminina <br /> in accordance with California Code of R.tgulatiotrs,Title 23,Section 2715(0)Mrough (1). Furthermore, I understand and am <br /> in compliance with the requirements(statutes, regulations; dnd local ordinaucrit) applicable to underground storage tanks. <br /> TANK OWNER NAME: <br /> TANK OWNER TITLE: _. CLy� 6� OWNER PHONE: (' 0C, ).2 J-7 a'k <br /> TANK OWNER SIGNATURE: DATE:���i/ly <br /> ._.,_ <br /> INST RUCTIDNS �--7-- <br /> 1. Repan the name(s)of the Designated UST Operators)as gistemd with die lijmmarional Code Council (ICC). ICC cartifrcalion <br /> information isavailable on-nine at:wwsv,iccsaleorgre/eerq rth.letsaL Search fpr"Caiifornia UST System Operators." <br /> 3. Submit this completed form to the local agency that raga ones This facility's )JSTs. Unidecs member agency jurisdictions and <br /> contact information aro listed en-line ac www.unidoes.o g/memhenrwhore(,ulateswital.html. Contact information for other <br /> local asuncies wz1hia CaUfomia L available at: V,ww4*'reb. a.9&V/ewPhome/a9l/CDP tacts/dacs/Iacul�a6CYCy LULr15. <br /> 3. <br /> 2, CCR P71i(a)requires that yeu notify the local agency o any changes w this linformation within 330 days ofthe date of change. <br /> IrN-062-IA w"w aolaaciore oy23ros <br /> ('d B££ l l l l 66 ABA <br />