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Feb 25 09 11:02a Francene Escobar 2098254539 <br /> %W ../ R�U22,f2 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPE <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQU <br /> Mi VP <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited.• Title 23, Div, 3, Ch. 16 California Code of Regulations(CCR) <br /> FACILITY NAME �y FACILIITYPHHONE <br /> U IC-Kt 40 V4-0_ l C:tQ✓GL✓.yr (�",,I ) SrY <br /> FACILITY SITE ADDRESS CITY <br /> REASON FOR SUBMITTING THIS FORM(Check One): Z Change of Designated Operator Update of1CC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: Nikola Za9orov RELATION TO UST FACILITY(Check Om) <br /> BUSINESSNAME(Idderenrfromabave): EPIC Compliance Systems ❑ Owner ❑ operalor ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (688) 700-EPIC exL ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5264361 - UC EXPIRATION DATE: 702(2009 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY O 'onaf <br /> DESIGNATED OPERATORNAME: Bryan Dunahay RELATION TO UST FACILITY(Check Om) <br /> BUSINESS NAME(1fdffarenrfromabove): EPIC Compliance Systems ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERA FOR PHONE: (888) 700-EPIC ext, ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 802436 - UC EXPIRATIONDATE: 1216/2010 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: Al Milburn RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(ffdi�erenrfrom above): EPIC Compliance SYStemS ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATEDOPERATORPHONE (888) 700-EPIC ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 0878949 - UC EXPIRATION DATE: 12/(3/2010 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(O tion <br /> DESIGNATED OPERATOR NAME: C,._ o N D RELATION TO UST FACILITY(Check Ox) <br /> BUSINESS NAME(Ifdrferrmfromabou): /��� c� LtJ Owner ❑ O erator <br /> C r ('• � , p ❑ Employee <br /> DESIGNATED OPERATOR PHONE: �a ) O Z _etc— kxt• u Service Technician El Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: ++ �,`�• EXPIRATION DATE: % <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated LIST <br /> Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Cade of Regulations, Title 23, Section 2715(c) through (Q. Furthermore, I understand and am <br /> in compliance with the requirements(statutes,regulation local ordinances)applicable to underground storage tanks. <br /> TANKOWNERNAME: C Ur b —" p, <br /> TANK OWNER TITLE: © /� JZ OWNERPHONE: <br /> TANK OWNER SIGNA RE: DATE: (S <br /> INSTRUCTIONS <br /> I. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council(ICC). ICC certification <br /> information is available on-line at:www.icesafe.org/e/certsearch.html. Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and <br /> contact information are listed on-line at: www.unidocs.org/members/whoregutateswhat.htmi, Contact information for other <br /> local agencies within California is available at: www.swreb.ca.gov/Cwpliume/ust/contacts/docs/]ocal—agency_list.xls. <br /> 3. 23 CCR §2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. <br /> uN-0612-IA r cvAZ ` ` �P , �� 3� <br /> nx•w.unidoa.org 09/22/05 <br />