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LNDEPGKOUND -STOR,kGE TANK SYS7Pi
<br />OWNER STATEMENTS OF DESIGNATED I fS-r (,)PEFcA'T0R-
<br />UNDERSTANDING OF AND C0rvjPLLAC\,F, V,,'IT-H UST Ft E0 T
<br />L1REMENTS
<br />Dir 3- Ch 16 Cafijbwnia Code lcf;I
<br />-,R) ,
<br />Facility Name:
<br />iTY Ph(Ine
<br />�Facility Address:
<br />Rc,*071 for SLjbjjjjUjng this f ol rrj
<br />7, L-yirwl,�li Date
<br />Li Ch,,inpt� of D -s T
<br />Desi oared —Ul�Otk�*Ator s�for this Facilin,
<br />BL1Sirt(-,ss Name: BZ Sell -ice Station Alainteoance, Inc.
<br />Address: 1041 Triangle Ct, - kektticln to USTFacility (Cha( -k One)
<br />N� est Sacramento, Ca 95605
<br />Owiier � Operator L7 EmploNe,-
<br />Dcsipated Operator's Phone 1, 1 1 Y
<br />916-371-238() bird -Part}
<br />T,�(1-111`ciarl x Th i rd
<br />Stall ruder
<br />Oder
<br />5244364 -UC
<br />5250317 -UC
<br />1 '21); 16
<br />V28,47
<br />I
<br />1 certify that, for thje facility izidicaied ai the top of this page, the individu-Flif, s) lined abovc will
<br />ser%�e as Designated UST Oper4tcr(s-), The individual(s) conduct and docurfic.tit monthly
<br />facility, inspections and allnual facility employee training, in accordanct th Ca.fifomia Code c f
<br />Regulations, title 23, section --7`7 15 Fuj-1tri-nore-1 wide-rsTwid and am incompliance wit')
<br />the rc,-quiremei-iis (sTart-IteS, fegulaiion�s, tinct I .
<br />C7 -1 local or(finances.) apol cab'- To �a -ag
<br />tanks. - I - nderground stoi t:,
<br />TANK OWNER NAME: S i 0
<br />TANK OWNER. TITLE: Lj I Li I
<br />TANK UIKNER SIGNATURE: f. I ILI—
<br />the name(s) of thc Dt�iP-HaLcd LST 01)r_Faco I-(. Sj aS rcgisjara,ji ,s I ti. the Injer-li atw, F;, a I Cnd, COLU16 I (ICC). ICC
<br />certification inf-,)mjjc(c)rj is avqjijabjc or-firif.
<br />at:
<br />Operators.,'. — h !"01 -C- a[ iforni a UST syste 1-1
<br />2. Submit Ellis coni letA ibi Pri t,2 0 1& local aoen�--,, that tk.ii I acd, i L S I
<br />3. 23 CCR 271 5(a) rcquirci 4)4, -,��A; 110zi I I fh,: iL)c a! I �;cncv of -dn% --h I Fjp_��Cu
<br />1'! 3 L) 1�a\- L) f rh �-, cla I
<br />ut changC.,
<br />ij 4'r -,7lV -a -i c 16
<br />, 0 :
<br />vtsi .
<br />—1
<br />gnatcd Operator's Name
<br />Icc#
<br />Expiration date
<br />Alexander Tate
<br />�81966193-UC
<br />2/4,16
<br />v
<br />avid Rouse
<br />32925 30 -UC
<br />4!-2-5/17
<br />James Williams
<br />525212-,4-LrCC
<br />7
<br />F4 . 7,1
<br />Jeff Brown
<br />5'20,17
<br />Jeramy Cummins
<br />i 809661-uc
<br />1 7/2:16
<br />Kelvin Cruz
<br />i._._-_
<br />11�
<br />3016282 -UC
<br />i ------
<br />8/1317
<br />Stall ruder
<br />Oder
<br />5244364 -UC
<br />5250317 -UC
<br />1 '21); 16
<br />V28,47
<br />I
<br />1 certify that, for thje facility izidicaied ai the top of this page, the individu-Flif, s) lined abovc will
<br />ser%�e as Designated UST Oper4tcr(s-), The individual(s) conduct and docurfic.tit monthly
<br />facility, inspections and allnual facility employee training, in accordanct th Ca.fifomia Code c f
<br />Regulations, title 23, section --7`7 15 Fuj-1tri-nore-1 wide-rsTwid and am incompliance wit')
<br />the rc,-quiremei-iis (sTart-IteS, fegulaiion�s, tinct I .
<br />C7 -1 local or(finances.) apol cab'- To �a -ag
<br />tanks. - I - nderground stoi t:,
<br />TANK OWNER NAME: S i 0
<br />TANK OWNER. TITLE: Lj I Li I
<br />TANK UIKNER SIGNATURE: f. I ILI—
<br />the name(s) of thc Dt�iP-HaLcd LST 01)r_Faco I-(. Sj aS rcgisjara,ji ,s I ti. the Injer-li atw, F;, a I Cnd, COLU16 I (ICC). ICC
<br />certification inf-,)mjjc(c)rj is avqjijabjc or-firif.
<br />at:
<br />Operators.,'. — h !"01 -C- a[ iforni a UST syste 1-1
<br />2. Submit Ellis coni letA ibi Pri t,2 0 1& local aoen�--,, that tk.ii I acd, i L S I
<br />3. 23 CCR 271 5(a) rcquirci 4)4, -,��A; 110zi I I fh,: iL)c a! I �;cncv of -dn% --h I Fjp_��Cu
<br />1'! 3 L) 1�a\- L) f rh �-, cla I
<br />ut changC.,
<br />ij 4'r -,7lV -a -i c 16
<br />, 0 :
<br />
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