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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Quickie Kleen Facility ID#: <br /> Facility Address:707 E.Yosemite Reason for Submitting this Form(Check One) <br /> ❑ Change of Designated Operator <br /> Facility Phone#:209-814-6274 ■ Update Certificate Expiration Date <br /> Designated UST ODerator(s) for this Facility <br /> PRIMARY (Optional <br /> Designated Operator's Name: Tojan Smith Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:661-363-7400 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5262033-UC Expiration Date:8/16/09 <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: At Milburn Relation to UST Facility(Check One) <br /> Business Name(Ifdi/ferentfrom above): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:661-363-7400 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 0878949=UC Expiration Date: 12/5/08 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name({(different from above): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:661-363-7400 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 37 (Optional) <br /> Designated Operator's Name: Ronald Briddick Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above):CHAMPION PRECISION TESTING INC ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:661-363-7400 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5256869-UC Expiration Date:3/7/09 <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) - (f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicayle to underground_storage tan . <br /> NAME OF TANK OWNER(Please Print): I-1Tu Pc -e N,-F S/ C— 0 u Q <br /> SIGNATUREf/ OF TANK 7 OWNER: c--- ' ,--f f� � ry�`� <br /> DATE: 0 0 J OWNER'S PHONE#: C/o/� 6 _30 r� � <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: <br /> www.waterboards.ca.Cov/ust/contacts/cul)a agys.hunl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> Page 1 of 1 November 2004 <br />