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Jun 24 05 04:39p Afr -da-Test (209' 794-0112 New .iJ VCOOJJJU Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Faeftty Name: Facility 10 # : Facility Address:a ,43 i F-- /yt�(I ��p R son for Submittirg this Fonn (Check one) c- j I �t r�- - Change of Designated Operator Fadity Phone#: 2e19l cY4J-10 Update Certificate Etpiretion Date Designated UST Operator(s) for this Facility wruew Designated Operators Name: JANINE KIRBY ReWion IoUST Fadisy (Check one) 0 Owner' 0 Employee 0 Service Technician 0 Operator ■ Third Party Business Name (If different from above): USTanx Designated Operator's Prone #: (530) 268-3949 Intemaiunal Code Council Certification 0: 5244224•1.11C Expiration Date: 1010212006 xr TCRNeTF 1 lrfn afl P. 3 Desgnatad Operators Name: RANDALL KIRBY Relation to UST Facility (Check ane) 0 Ovmer 0 Employee 0 Service Technician 0 Operator IN Third Parry Business Name (If different fmm above): USTanx Desgnated Operators Phone #: (530) 266-3949 International Code Council Certification # : 5250566 -UC Expifation Date: 12/28/2006 Al TFRNATP 2 lnnffmall designated Operators Name: TERESA KIRBY Relation to UST Facility (Check ane) 0 Ovmer O Employee 0 Service Technician O Operator ■ Third Parry Busirxtn Name (If d#ten>nt frown above): USTanx Deslgrlatea Operators Phone #: (530) 268-3949 IntematioraJ Code Council Certification 9: 5244507 -UC Exp'Iratior Dale: 1 0123120 0 6 ALTERNATE 3/OnSonaO Designated Operator's Name: LY L G 11A \ Relation to UST Facility (Check one) ❑Owner O Employee 0 Service Technician 0 Operator O Third Party Business Name (X dilfereM from shove} Designated OPeMWS Phone #: 'Z69 --794/-101672- International Code Council Certification #: ITQ C 111,7.,tleExpiration Date: fel a NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. I certify that, fw the facility ira7fl-jtad el the top of this page. the Individual(s) Sebd above will some as Designated UST Operator(s). The Individual(s) well conduct and dobument monthly facility witspritfone and annuaf facility, mpioyee train'mg, in accordance with Callfomla Code of Reguixtions, title 23, section 2715 (c) - (1). Furthermore, I understand and am in compliance with the requirements (statutes, reguatlons, and local ordinances) applicahle to underground jutorage Tank, NAME OF TANK OWNER OR OWNER'S AGENT (Please Print) : C �_ A� SIGNATURE OF TANK OWNER OR O�sW�NEIrS AGENT S LO L, OAT'.c'7r•-��.J� OWNEWSPHONEX: p.2