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013/12/2,010 13:15 FAX 17074466192 TANK-TEK IM 004/004 <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING OF AND COMPLIANCE WrM UST REQUIREMENTS <br />For use by Uni&cs Mmibw Agencies or where approved by your Local Jurisdiction <br />Azahority Cited- 7stig 23, Div. 3, Ch 16 California Code of Regulations (ca?) <br />JIM <br />FAClLrrY PHOM <br />yj - 4 11911(1 jet -if Ii <br />09-9574900 <br />FACILITY SrrP- ADDRESS <br />TGNATED OPURATOX PHONE: (707) "S-61 51 wa. <br />3202 W. HAMMER LANE <br />z <br />0 '"T -Tr W1-TVTT-1- 4"! V I Z It b 0, 0 �4 Is 12 -TV <br />r, <br />s �,o , I ,� off P Vvi <br />b9�MNATMOPEVATORNA102: FachardThomas <br />M: .ATIOA TO UST FACILITY (0mck0w) <br />BUSDMSNANW((f rofflftol"abovd).- TiafnX-Te—k Environmental Corp. <br />owner Ej Operator <br />Service TeduUdan <br />Employee <br />Tldrd-ParV <br />TGNATED OPURATOX PHONE: (707) "S-61 51 wa. <br />TION CODE CoUNM CERTIFICATION NO-: 5254736 -UC <br />;P <br />-- -- — <br />0 ra <br />DES D Oi�TQR NAME, <br />RELATION TO UST FACILITY (Chffck One) <br />Owner 3 Opetator <br />Service Technicim <br />E] Employce <br />Cl nird-Party <br />BUSMS NANM (yd0Vb%wfrom abow)-' <br />REL TIONTO�USTF ACILITY (Check Orm) <br />�=E] <br />owner El operawr <br />El Emp)ore <br />rl Serne, Tedmician <br />Third -Party <br />*Y-Tz,P.V4n��U# TED IUST xVS X*,!WLtATY MzWot-AO <br />I cul* that, for the facility indicated at the top of this page, the ludWilual(s) listed above will serve as Designated ITST <br />Operater(s). The ludividual(s) will conduct and document monthly facility inspections and annuAl facility employee training <br />In aemrdance with California Code of RAgulations, Tffle 23, Section 2715(c) through (f), Furthermore, I understand and am <br />In compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tank& <br />TANK owNERNAi-AB; CP -LLC / Designee. Armen Mkrtychiarl <br />TANKOwNER=: Compliance Manager OWNERPHONE: ( 925 ) 884-0800 <br />TANK OWNER SIGNATURE: DATE: z;s cW. ID <br />XN,S�UCTIQNS <br />1, Report the ume(s) of the Designated UST Ope=r(s) as registered with the Intonational Code Council (ICC). ICC certifleadon <br />bdbrmation is ZVKHAND On-line atWWW-iCAMff--org/c/cwtumrch.btml. Search for "California, UST System. Opamtors," <br />2. Submit this complaed form to the local agency that replato this facility's UST9. Unidocs maznbw agency jurisdictions and <br />contact <br />info on we fisted on-line at: www.unidoo.org/membao/wboagWatawbaLhtmL CORW infonnation, for odw <br />local agencies within Caftmia, Is available at wwwswmb.eLguv/cwpbomatuvcontacwdoesAncaLigoury__�bLIb. <br />1 23 CCR §2715(a) requires dw you not* the local ageptcy of any changes to this informadon witWn 30 days of the dm of change. <br />UN -062 - V1 w%ww.wddomcrg Wmq <br />RELATION TO UST FACUdTY (Check Ow) <br />13 0-ncr 0 op-erazor Cl Employee <br />F-1 Service Technician 0 Third -Pam <br />NNN" <br />RnMATIONAL CODE COUNCIL CERTIFICATION <br />VIV-441T.11.vh► r IY�� <br />I cul* that, for the facility indicated at the top of this page, the ludWilual(s) listed above will serve as Designated ITST <br />Operater(s). The ludividual(s) will conduct and document monthly facility inspections and annuAl facility employee training <br />In aemrdance with California Code of RAgulations, Tffle 23, Section 2715(c) through (f), Furthermore, I understand and am <br />In compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tank& <br />TANK owNERNAi-AB; CP -LLC / Designee. Armen Mkrtychiarl <br />TANKOwNER=: Compliance Manager OWNERPHONE: ( 925 ) 884-0800 <br />TANK OWNER SIGNATURE: DATE: z;s cW. ID <br />XN,S�UCTIQNS <br />1, Report the ume(s) of the Designated UST Ope=r(s) as registered with the Intonational Code Council (ICC). ICC certifleadon <br />bdbrmation is ZVKHAND On-line atWWW-iCAMff--org/c/cwtumrch.btml. Search for "California, UST System. Opamtors," <br />2. Submit this complaed form to the local agency that replato this facility's UST9. Unidocs maznbw agency jurisdictions and <br />contact <br />info on we fisted on-line at: www.unidoo.org/membao/wboagWatawbaLhtmL CORW infonnation, for odw <br />local agencies within Caftmia, Is available at wwwswmb.eLguv/cwpbomatuvcontacwdoesAncaLigoury__�bLIb. <br />1 23 CCR §2715(a) requires dw you not* the local ageptcy of any changes to this informadon witWn 30 days of the dm of change. <br />UN -062 - V1 w%ww.wddomcrg Wmq <br />