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09/21/2001 01:57 2098325518 GRANTLINE BEACON PAGE 04 1" &x'-) t" Owner Statements of Desi ted Underground Storage Tank (UST) Ope and Understanding and Compliance with UST Requirements Facility Name: F8lcility 1t7 x Faci)ity Address; J'R 3 � RsaAon for Submittwg tori Form (Chao O Charge of Dd7gnOw operator Fac i tY Phone # : oZ U q g 3313 update Gart)ficarr E ►ratfpn Data PRIMARY ill serve as Designated U5T Upe s). The individual(l) will C,OMUCt and document m in Accordance with California C- Designided e: Ed 54ernv Relation to UST Facility (Geck one) i Bvainess Name (H diflererd train atwMe): cnam Pn�+or TWOg Inc. 0 C)wner C Employee o Service echnfcian [lesirjnAed Operawit Phone x 916 927-15 C operator ■ Thad Party NAME OF TANK OWNER �p Sh A Mt t�N OR OWNER`S AOENT (Please int) International Code Council Ceditatfan 92 -UG Eviration Date: t?J1t312QOS ALTVRNATE I (OpWnen OWNER OR OWNER'S AGEN Designated Operator's Name: ReIlllion to UST Focally (Ci►eckone) Busirwr, Name (ff diffWent from ab—): ❑ Owner q EmployYe ❑ Serrlce pcilrwtan Desrgndtod t7perator's Phone #: C Operaior M Third Party i International Code Caxx d Coww-abmi #! — E)Prahon Date: ALTERNATE 2 (OpWnel) p"ignatold Operators Name'. Relatlon to UST Facility (Check one) Busirws9 Name (if di WVAfrom WV -Y 0 Owner 0 Employee d i ectmician Designaesd Operator's Ptwne �F D Operator Is Third Paoli International Cade Gouncl Certificatim 9: Expiration Date9 ALTERNATE 3 (000na!) Designplod Operators Name: RofaGrrr to UST Facility (Check one) Business Name (If dPffererrt from ahwsl' D Owner 0 emp" Cl `Technician Designated Operators Phone*: C' Operator a Third Part Iitt6rriallonal Gone Council Ceriiflcarion E : bi Eipirafion Date: Al NOTE: THE LOCAL REGULATORY A GY MUST BE NOTIFIED or ANY cHANQE5 TO TIi1S INFO WITHIN 30 DAYS OF THE CI A I certify that, for tt)e faculty indica at the trip of this page, the irldividual(s) listed above P ill serve as Designated U5T Upe s). The individual(l) will C,OMUCt and document m in Accordance with California C- 4e of facility inspections and annual fa employee training, Reguistions_ title 23, section 271 ) - (f), in compliance with the requirements (statutes, �I Furthermore, i understand and rsguatione, and local ordinar»G ) applicable m underground storage tanks. NAME OF TANK OWNER �p Sh A Mt t�N OR OWNER`S AOENT (Please int) SIGNATURE OF TANK OWNER OR OWNER'S AGEN : b DATE: I �- OWNER'S PHONE #.- 1 -17-LAOI5 IKON 02:34 TEL: 2091 23542 NAME:RANBIRIIS P.