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Jun 24 05 04: 40p Rff� Test (209) 4-0112 p. 4 <br /> Ge - - - --- —- .. ----VJJJ� r.M <br /> - i <br /> Owner Statements of Designated Underground Storage Tank(UST)Operator <br /> and Understanding of and Compliance with UST Requirements i <br /> Facility Name: Facility 10;;: <br /> Facility Address ($5 f c� ��]ub in l�a Reason for Submitting this Form(Cheat one) <br /> V 6 D 1 mange of Designated Operator <br /> Facility Phone#: 0 Update Certificate 00ration Date <br /> Designated UST doerator(s)for this Facility <br /> PRIMARY <br /> Designated operators Name:JANINE KIRBY Relation to UST Facility(Check one) <br /> Business Name(if different ham abover USTanX 0 Owner 0 Employee 0 Service Technician, <br /> Designated Operator's Prion 9:(530)268-3949 0 Operator ■Third Party <br /> international Code Council Certification#:5244224-UC Expiration Date:1010212006 <br /> ALTERNATE i(Optfonsq <br /> Designated Operator's Name:RANDALL KIRBY Relation to UST Facility(Check me) <br /> Business Name(if different from above}:USTanx 0 Owner 0 Employee 0 Service Technician <br /> Designated operator's Phone#:(530)268-3949 0 Operator A Third Party <br /> International Code Council Certification#:5250566-UC Expiration Date:12118/2006 <br /> ALTERNATE 2(Optionao <br /> DesigneWd Operator's Name:TERESA KIRBY Relation to UST Fad*(Check one) <br /> aininea Name(If dNferent ikon above):USTartx 0 owner 0 Employee O Service Technician <br /> Designated Operntots Phone 0:(530)268-3949 0 Operator ■Tr&d Party <br /> Intemationai Code Council Certification#:5244507-UC Expiration Date:10123/2006 <br /> ALTERNATE 3(Options!) <br /> Designated Operators Name: LY LE V46 N NA, Relation to UST Factity(Check are) <br /> Business Name(#different from shove}: 0 Owner 0 Employee M Service Technician <br /> Designated Operator's Phone#: -,&S9 -79q= /O Z 0 Operator 0 Third Party <br /> intemationat Code Council Certification#: — Expiration Date: )a <br /> NOTE THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br /> WITHIN 30 DAYS OF THE CHANGE. <br /> 1 carry that for qui,t'ac ft i unite at the top of flus page,alta individual(s)listed aboae wAl <br /> serve as Oes%pv ftd UST Operabr(s).The WOviduo(s)will oanduet and document mommy <br /> belliyF lnsdecdons and aftnual Udity employee nln ft.in a tdann with California Code of <br /> RapAdons,We 23..section 2715(c)-(f). <br /> I <br /> Fu Mannon,I widetstand and am In comoance Midi the requiremen%(statutes, <br /> rempadons,and laical erdirimmes)appli=09 to underground atarAgw Maks_ <br /> NAME OF TAW OWNER <br /> OR OWNER'S AGEMT(Rose Pring: /� eji4W <br /> ' H � <br /> SIGNATURE OF TANK <br /> i 0VA4E t OR OWNERS AGe4T: w2 <br /> DATA OWWOS PHONE*: 102 w <br /> 1 <br /> i <br /> y�,�•-dSrS <br />