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Apr 12 05 01:36p USTanx 5302683330 p.2 <br />M1 q�ty�yu�� rine 6302663330:0 q <br />>�, ,f.l V V,.LVo VJ• JVVtVVVJ� r�T <br />] <br />Owner Stakements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Fadaty Nano 33J <br />Fag7tly ID 0: FA 000 SOS 4- <br />Fecifity Address: I S -5S E,,.$+ VeSC.MCkero XVe.. <br />Reason fpr Suhmiting this Fonn(Check ane) <br />TMC r �. <br />• Change or Designated Operator <br />10 Update Certificate Fxpiralon Dale <br />Favi ty Phone R: a2 D 83 — Is i 711 <br />Designated UST Ooeratoffs) for this Facility <br />PRIMARY <br />Designated Operators Name:.)ANINE KIRBY <br />Rotation to !1ST FaciHy (Check ane) <br />Owner I Employee D Servi]z Tecnniclan <br />D Operator ■ Third Party <br />0]dness Name (1(d'Alerent horn above): USTanX <br />Designated OPsralors Pion;: (530), 949 <br />Inhi atimal Code Council Certification #:5244224 -LIC <br />Fxpiawn Dale: 1 womo06 <br />ALTERNATE 1 (OWwa() <br />Designated Operators Name: RANDALL KIRBY <br />1 Rel Winn to UsT Fatuity (check one) <br />10 Owner O Employee 0 Service Technician <br />0 Opeator ■ Third Party <br />f ,sines Name Iif diReren from above): USTanx <br />De.lgre6±d Operators Phone is (530) 268-3949 <br />InlematpnW Code Colnal Cenllicatiort 0:5250566 -UC <br />I Expiration Date: 72/28!2006 <br />ALTERNATE 2 fOydona7 <br />Designated Operators Nairne: TERESA KIRBY <br />Relation to UST Facility (Cneckone) <br />O Owner 0 Employee 0 Service Technician <br />0 Operator ■ TIwd Party <br />Business Naas (If rlReren fmm above): USTanx <br />Designated Operalors Phone K : 4530) 266.1949 <br />Interna]omt Code council Certlficafion 0:5244507 -UC <br />Expiration Date: 162312006 <br />ALTERNATE 3 (t pOenar) <br />Designated Opece rs Name: <br />Relation to UST Fanny (Chep] tine) <br />0 Owner O Employee o Service Technician <br />0 Operator 0 Third Parry <br />Business Name (if different from above} <br />Design Wed Operators Phone a: <br />Inle national Code Council CenPiration 0: <br />En tram Data: <br />NOTE THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br />WITHIN! 30 DAYS OF THE CHANGE. <br />I certify that, for the facility indicated at the top of this page, the individuals) listed above will <br />serve as Designated UST Operator(sX The individual(s) win conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Cade of <br />Regulations, tine 23, section 2715 (c) - (f) - <br />Furthermore, 1 understand and am in compliance with the requNen fonts (statutes, <br />reguations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER G1NT' <br />OR OWNER'S AGENT (Please Print); k. M (A(EA" <br />SIGNATURE OF TANK r <br />OWNER OR OWNERS AGENT: " (& <br />DATE: !411A[106 ...... OWNER'S PHONED: L9 (S)3 q-4 — I <br />