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02/27/2009 16:32 FAX 17074466192 TANK-TEK <br />IA 002/004 <br />0NMERGROUND STORAGE TSYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING Off' AND COMPLLANCE WrM UST REQUIREMENTS <br />For we by Unidoes Member Agencies or where gpgroved by your Local Jurisdiction <br />Authoriry Cited: Title 23, Div. 3, Ch 16 California Code of ltagulations (MW <br />FACILITY NA a <br />C RLLC #270 <br />FACILITY SITR AI)I?WS <br />1403 COUNTRY CLUB BLVD <br />MASON rOR SUBMIMNO THIS FORM (Cheque Pm): 129 Change of Designated Opcnuor <br />iis):gt0 t"li't14IIP! llIkl <br />DESIGNATED OPL'•RATORNAME- Virginia l:ullgaro <br />nusuxnss NAM>' (/Iclllrlerorll from abo Tank -Tek Em <br />OPEtiATOR PIONn: (707) -6161 ext_ <br />iAL COnh COUNCIL CERTti CATrONNQ.: 89226dd-1-IC <br />Update of ICC Cordfleadon Expiration Drttlaj <br />FACILITY (ChacA OW) <br />Q Owner ❑ Oparator [] nmployae <br />❑ Service TaChnielsn ® 1111rd.I'arty <br />TWIRATION DAIN: <br />msIGNA= OPERATOR NANIH: Michael (Mike) Lawrence <br />RKLA•PM rO UST FACILITY (Ch kOne) <br />® owner ❑ 00-utor I3 Employem <br />I�ugiN>:S9 N tUdilTT l abowuJ: Tank -Tek Eitavir Inmental Corp. <br />DESIONAInvo OPMATolt PI&ONP- ext, <br />® Service Touhnician ❑ Third-Pnrty <br />DIISIONATED 0?hRA'MIt MONII: (701) 446-6151 ext <br />WT TIONAL C OJ)A (.'Ot)NCit CdtTIFICATION NO.: J 103 -UC <br />.hr Res„ -fpr+ <br />ATIAN DATE: 10i1 212009 <br />DESIGNATED OP)MATOR NAME, <br />FII;1.A'riON 11n UST FACILITY (Ckock OnO <br />❑ Owner ❑ Opmw ❑ }3rnployee <br />® servies 7'ectimet n ❑ Third -(Party <br />RUSBCS NAME (p''d'eranr,l'h abow,l: <br />DESIONAInvo OPMATolt PI&ONP- ext, <br />INTONATIONAL 0008 COUNCIL CF.R'rIVICA710N NO.: <br />EXPIRA770N DATE <br />DESI04ATED (FERA•I OR NAIYM. <br />RELATION TO V1T1' FACILrrY (Cheek OnO <br />Owner ❑ Op=or ❑ Employc e <br />❑ Servios Technician ❑ Third -Parry <br />BUSINESS NAME ({f' Iftrentfrom above): <br />DBSIONA:MD OPMATOR PI <br />INTORNATIONAL COW COUNCIL CERTIFICA110N NO.: <br />ExPiRATION DATE: <br />I ccrft that, for the facility indicated at the top of this pW, the indMililai(s) listed above will serve as Designated UST <br />Operator(a). The indlvldual(s) will conduct and document monthly facility inspections and annual facility employee training <br />In accordance with California Code of lksgulations, Tide 23, Section 2715(,) through (f). Furthermore, I understand and am <br />in compliance with the roquhvmcnts (statut—ess,�regulations, and <br />/local ordinances) applicable to underground storage took& <br />T OWNER NAME: G6V • (i� , <br />TANK o Trrz.s: YYit�haq 7v9Q1? A�[GI%' owly rlaorl�: t 9zs') 8S`�`D <br />TANK OWNER <br />Raport the nam*) ofaignttted UST Operawr(s) as registered with the Internationai Code Council (ICC). ICC cortircation <br />mform�ation is available M.icc$2fe.org/e/oortsearcb-html. Search for -California UST System 0 S./0 <br />Submit this comploted form to the 16W apacy that regu)atas this facility's UST's, 'Unidocs member agency jurisdictions and <br />coamt information; www.unWats.orgnnembcrs/wboregulatmwhat htmL Contact lnformatlon for other <br />local noes within C � e at, www.swrob.co.gov/cwphome/usticontmets/docoAccoLuts.encyjlst.xb. <br />23 CCR 62715(a) mqui a local OPMY of any changes to this information within 30 days of the date of change. <br />UN-NG2 - !h <br />www.unW .arp 09/iM <br />