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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Fadfiry Name: Fadlify ID It: <br />Facility Address: kcb % .leQES�A 0 £� Reason for Submitting this Form (Check one) <br />Q M Change of Designated Operator <br />Facility Phone # : O Update Certificate Expiration Date <br />PRIMARY <br />'Cl Operators Name: Jr <br />Name (If dlHerent from <br />Id Operators Phone #: <br />'al Code Council Cenif <br />All CKNAIE 1 (Optipnan <br />Desianated UST Ooerator(s) for this Facility <br />;lation t0 UST Facility (Check one) <br />Owner ❑ Employee ❑ Service Technician <br />Operator ■ Third Party <br />Data: <br />Designated Operator's Name: RANDALL KIRBY Relallon to UST Facility (Check one) ' <br />Business Name (If ditrent Som above): USTanX D Owner ❑ Em <br />ployee q Service Technidar <br />Doatgnated Operator's Phone #: (530) 268-3949 0 Operator R Third Parry <br />Intemationat Code Council Cennicaton #:5250566-UCExpiration Date: 12/28/2006 <br />ALTERNATE 2 (Opffona/l <br />Designated Operator's Nama f TERESA KIRBY Relation to UST Facility (Check one) <br />Business Name (If different from stove): USTarut ❑Owner ❑ Em I <br />p ogee ❑Service Technician <br />Designated Operator's Phone #; (530) 268-3949 O Operator AI Third Party <br />tntemational Code Goundl Certification # :5244507 -UC Expiration Date; 10/23/2006 <br />ALTERNATE'3(OP4, <br />Designated Operators Name: JASON KIRBY Relation to UST Fadiity (Check ane) <br />Business Name Of different from above): USTanx ❑ Owner ❑ Em <br />Dasignated Operators Phone X; 530 2683949 pbyee O Service Technician <br />(. ) Operator ■ Third Party <br />International Code Council Certification #: 5270158 -UC EXpindon Date: 10101!2007 <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 individual(s) listed above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, Section 2715 (c) - (t), <br />Furthermore, I understand and am in compliance with the requiremants (statutes, <br />reguations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER <br />OR OWNER'S AGENT (Please Print) <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: OWNER'S PHONE #: <br />