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I ' <br /> Jun 24 05 04t24p off da-Test (209 '94-0112 p. 2 <br /> ,�.. Owner Statements of Designated Underground Storage Tank(UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facifity Nance: r Fadlity�V: <br /> Facilty Address: j$51 n iYy�' Reason for SubmOting this Form(Check ore) <br /> 02 <br /> • Change of Designated operator <br /> Facility Phone 0:69e22 0 update Certificate Expiration Date <br /> Desigoted UST Operatods farthis Facility <br /> PRIMARY <br /> Designated Operator's Name:JANINE KIRBY Relation to UST Facility(Check one) <br /> Business Name(if different from above):USTanx 0 Owner 0 Ernplayee 0 Service Technician <br /> Designated Operator's Phone#:(530)268-3949 0 Operator ■Third Party <br /> International Code Council Certification#:5244224-UC Expiration Date:10102/2006 <br /> ALTERNATE I(CpSona1) <br /> Designated Operator's Name:RANDALL KIRBY Relation to UST Facility(Check one) <br /> Business Name(If different from above):USTanX 0 Owner O Employee 0 Service Technician <br /> Desokftd operator's Phone#:(530)268.3949 0 operator ■Third Party <br /> International Cade Council Certification 0:5250566-UC Facpit'ation Date:12128/2006 <br /> ALTERNATE 2(OpUonaf) <br /> Designated Operator's Name:TERESA KIRBY Relation to UST Faciity(Cheek are) <br /> Business Name(If dalerent from above):USTanx 0 Owner O Employee 0 Service Technician <br /> Designated Operators Phone#:(530)268.3949 D operator ■Third Party <br /> International code Caul certification#:5244507-UC Expiration Date:10/23!2006 <br /> ALTERNATE 3(Opdonaf) <br /> Designated Operator's Name: LY L.E nNh6jbW Relation to UST FwAity(Check ane) <br /> Business Name(a different fron abovek 0 Owner 0 Employee Q Service Technician <br /> Designated Operator's Phone S: •Z09 y_Q/(y z E3 Operator 0'third Pally <br /> IntemeknO Code Cowd 4ffaft <br /> NOTE:THE LOCAL REGIJLATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO TMS INFORMATION <br /> W THLN 30 DAYS OF THE CHANGE.. <br /> I0ABY R~to UST Fad* ore) <br /> Brame nN Awe aooeoY 018•Ta9W O OWW GemowreftQ S pTsrB.e:Ktan <br /> OmstaPharmaat• sto a OPROW a TMdPe.ty <br /> jtMONNOW CodR R:30=04C Expkalkn Oak:t <br /> ALTEIMATE 2 MPOIWO <br /> are Nam;TERE8AKIRIIY kobdw noV3T Vadlity fChesRa») <br /> OddMIM NOM IN sea iJg7ena o Own!' a Edo 0 sanke TeoWniefto>s <br /> IlMarnarraonal 09"t WAW COMMIlan 1p; -UG figo OMJL1 <br /> N♦aree Y I. 1Roswo oulrf Fns(Chsrarar+a) <br /> fitmdroesNow(rambned WDnwr C1 OWW O Em •Smvk*Tadvolden <br /> P110fneR: - '+ a Op"ater a Tose Pavy <br /> NOM TM LOC^L fZGGISLATOW AGEMY WlJW 96 WMR0 Of ANY C TO TNlS WFUMAATNON <br /> WATNIN IK DAYS OF THE <br /> I gnat for tta favi tr indimtm At the top of"S pp9%rt kW,. a)osW >wAal <br /> servo as UST opsrRtpl(s).The' - uiat(s)will oon&v and domrient monthly <br /> fta. Msoactions tend annual fadNty&mpkwft training.in wit C rftrf is Cafe of <br /> %guftpons,On 23.secdon 2715(c).M- <br /> 1 <br /> t <br /> F 'relNfa(s• ran.,t d Rne.n,In ego ce witheav <br /> rerAttom.anon joicai®mitt )applicsWe to V f"nd x01r2W 11011 s. <br /> E OF TANK Fat �)(1 A <br /> OR t�11N A T(" Print) Q,9T Lt /S Ni <br /> Slem^TURE OF TANK <br />