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Apr 1808 08:53a Francene Escobar 7^98254539 p.2 <br /> U <br /> LNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIA-NCE WITH UST REQUIRE-11IIENTS <br /> For use by Ueido❑r.4fam6erAgcmies or where approved by yadr Local Jurisdiction <br /> Awhori{v Cited: Title 23,Div. 3, Ch. 16 C diforma Code rf Ragulariora(CCR) <br /> F.AC[u NAV rr n A ' 1 'AC]( 'Y Px <br /> F.ACII.J'I' SITE AD[]WL ,•c+G W CITv' <br /> PLEASON FOR SUBMI:7ENG THIS FORM(Check Ora): Achangcofc1esiontmedopmtor Lj Update of ICC C;erliFe+uio Expiration Dates) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESICNA'IPr.OPERATOR NAME: Nlkola ZagoroV Ria-A'I'IONTO USC FACILPI'Y(Ch"*Gnx) <br /> BUSWE55 NAME(ifdl;yvr,vrrfrosoaba�el: EPIC Compliance Systems, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> OESIGNATEDOPEMCORMONE': 888) 700-EPIC ext.2 ❑ SGNII'e T¢ehaiQi&a ® tldrd-Party <br /> INTERN'A'110NAL CODE COUNCIL CERTISCA71CYN NO.: 62643131 _ UC EXPIRATION DA'Z'E. 7/1 212 0 0 9 <br /> ALTERNATE t DESIGNATED LET OPERATOR FOR THIS FACILITY( a <br /> DZSIGNATFD OPERATOR NAME•: Masoud Fatly RELATION FO UST FACILfI'Y(Cbeo.P th,a) <br /> HL'SINESS NAMF({fdiffnvj 4vm obow): EPIC Comphance Systems, Inc. ❑ Owner ❑ Operator ❑ Ernpluyec <br /> - DESIGNATED OPERATOR PHONE (888) 700-EPIC ems- ❑ Scrvicc"fecllaiclen �TT,Ird-Parry• <br /> INTER"NA'I"ZONAL CODE CYHINCILCER7'1FICATIONWO.: 53W56 - UC EXP1RA'I'IONDAT12: 7M212009 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optleoap <br /> DPSICNATGD OPERATOR NAME: X11 Milbum RL-l.ATION'1'0 UST FACfUfY(CI.ck Ou) <br /> EUSINCSs NAME W'df(erantfrow abenr): Epic Compliants Systems, Inc. ❑ Owner ❑ Oparator Employee <br /> DESIGNATED OPERATOR V ZONE: (S88)700-EPIC ext. ❑ `"�'�' Tcadlniciau 'third-is;ury <br /> iNTERNATIONALOOOEC)UNCILCMtl'IFECATIONNO.: 0878949-UC EXPlKAI'ION DATE' 12/66/2008 <br /> ALTERNATE 3 DFSIGNATSD UST OPERATOR FOR THTS FACILITY(OptloW <br /> DESICNA'CEDCPC•RA'tOR NAME' rZELA110N TO UST FACILITY jCa.ek One) <br /> aU51NESS NAME((fdi,gerewr%ran above). ❑ Ovaer ❑ Operalar Eaaployec <br /> D12SIONA7ED OPERATOR PHONE: s#. ❑ Servicc Techniciat ❑ Third-Pally <br /> INTERNATIONAL COUP COUNCEL CGWII F1.CATION NO.. EXPIRATION DATE; <br /> 1 certifv that, for the racility indicated at the top of this page, the individual($) listed above will serve as Designated USF <br /> Operator(s). The individual(s)will conduct and documont monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations, Title 23, Section 2715(c) through p). Furthermore, I understand and am <br /> in eomplia nee with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNER NAME: -FV0.1j <--e-Pte LSLdI�� <br /> TANK OWNER TITLE_ a- F` OWNERPHONE' <br /> TANK OWNER SIGNATUR DATE: <br /> �9C:VSTRUCTTONS <br /> L Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(1CC). ICC cerlifIcation <br /> information is available on-line at:www.icesol;e,org/e/c4Ddsearch.btmi,Search 5x"Cali romia UST System Operatm s." <br /> 2. Submii this completed form to the local agency that regulates this facility's UST's. Unidocs member agency jurisdictioaS and <br /> contact intormarion aro listed on-line at ww'w.uxidoes.org/Memben)whm•cgutateswhiLt.htnl Contact information for other <br /> local agcieies within California is available at: wwwswreb.ea.gov/cwphomelustfcoutaclsrdoes/local_agenew_tist.xh. <br /> 3. 23 CCR 2715(a)re vires that y u notify The local agency Df any changes to this information within 30 days of the date of change. <br /> U14-061U14-061- h 6�ca`� �(9 X27 Cy0 <br /> wWx <br /> J &CFl � E — 0 10 aoidws.orB aY/371a5 <br /> 10/Z0 3rD" -1-1IH NOFHU MEE&ET99 Zb :ST 000Z)ZI/VB <br />