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09/21/2001 01:57 2098325Ft8 <br />nr- <br />Owner Statements of Desi <br />and Understanding <br />Facility Natna: <br />FACillty Rddr.e ,, <br />Facility phone # <br />X09 <br />ALT'ERNAT 4 O tional <br />Designated Operator's Name: Donald BrAdiq <br />B1191nwa Narne (Ij-dlffaronr,Jlxim ahnve).,,.Cl <br />Deaig�reted Operator's Phone #_ 916-927-15� <br />�lotemAtional Code Council Certification Ik <br />ALT ERIN ATIT - (Opriond) <br />D4wignated Operator's Name ChuO-1 13111 <br />Business Name (f d ifferenr from above): CI <br />Designated Operator'% Fhrme #; 916-927-15 <br />Intemattona: Code Ccun K CWifeiltiort *1: <br />ALTERNATE 6 (Optlef d) <br />Designated Operator's Narru; Dan Boley <br />Businesa Nano (If difet from above). C <br />Designated Oprrster's Phcne # 916-927-15 <br />Intemad,nal Code, Council Certification #: <br />ALTERNATE 7 (Optional) <br />DeBignatea Uperator 5 Name: ^J+ • - u� <br />Business lVztne (Ildi/jucnt front above): < <br />Designated Operator's Phone Jt: 916-927-' <br />International Codc Council Certification M: <br />GRANTLINE BEAMN <br />"-I <br />ited Underground Storage Tank <br />and Compliance with UST Regi <br />UP <br />pUCIsrON MSTING INC <br />SS330322099 <br />PRECISION TESTING INC - <br />PRECISION TESTING INC - <br />I l-i:C <br />PRk.GS10N TESTING INC. <br />8949 -UC <br />facility ID #: <br />healon for Submitting. <br />M chw�ge of Design <br />Q Update Certificate <br />Relation to UST Facility <br />0 Owner a Operav <br />❑ service Technician <br />Expiration Date: 03/091( <br />Petition to UST Facilil <br />❑ owner C 0rm <br />❑ Service Technician <br />Expiration Date 1217 <br />Relation to UST Focilir, <br />❑ Owner Q (Vera <br />ci Service Tcclwician <br />Expiration Date: 12/17 <br />PAGE 02 <br />Form (Chad One) <br />wk Ore) <br />D Employee <br />Third -Party <br />eek One) <br />0 1✓tnployee <br />Third -Parry <br />eck One) <br />❑ Employee <br />Thud -Party <br />Relation to LIST Faotli ;(Check One) <br />2 <br />a Owner ❑ Opera r ❑ Ernploy0e <br />❑ 5erviCt Technician ■ Third -Patty <br />Expiration Date: 12/15P -- <br />I cctti£y that, for the facility indtb�) <br />at the top of this page, the Andividual(s) li d above wi.]l <br />serve a5 Dcsi;nated UST Opera. The individuals) will conduct and docuz nt monthly <br />facility inspections and annual f employee trmning, in accordance with C Tonna Code of <br />Regulations, title 23, section 27- (fl. <br />Furthermore, I understand aiu <br />regulations, and local ordinan <br />NAME OF'rA1VK OWNER (riease <br />SIGNATURE OF TANK d'%rNER: <br />DATE: 10 <br />M1 <br />tut in compliance with the requirements <br />) applicable to underground storage tall <br />ot): i - <br />Art � <br />Ow1NLR°S PHONE #: Y )�L 23-- <br />I <br />NOTE.- 1) SUBl.41T THIS C0'MVI.ETE Mt FORTo T� LOCAL AGENCY (NOT THE STATE ATER <br />RESOURCES CONTROL BOARD) B ANT.ARY 1, 2005. THE LOCAL AGENCY LIST IS AV AB1LE ATI <br />tuwy_W� <br />_ hoard .ca-Ru�,tl5t/C¢Q c c v5.iltml, <br />2) ©TIDY THF LCICAI AGENCY O H <br />Y CANGES To THIS INFORMATION WlTHTN 30 DAYS OF THE <br />CHANGE, <br />Page 2 of November 20(W <br />_ <br />17 -PARE:; MnN nP: -�4 TF1 :209e1542 NAME: RANBIP P <br />