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ti 01/08/2009 10:16 2094732344 MARCH LANE 76 PAGE 02/02 <br /> Qvvner Otaterrients of Designatect Underground StOr8ge TRnk(UST)Operator <br /> and Understanding ut and Complianoig with L18T Requirements <br /> FaGlIlly Name March Lane Union 76 Facility to#'255866 <br /> Add-&A;2701 -&MAAtfteh Lane, <br /> Wn', Agrszig Reason f4p 6this Farm f0heakenV <br /> ChanPe OF De aIpn;jtRd Opwator <br /> ------- fl I)PdAte Carfifinf.r. Iratta"Data <br /> PMMARY EftZHI& <br /> DBSi dated Operators NAM&,RANn LL mKoy <br /> 1101Re to UST Facility ne3a Norm(j,unmrant from abav6):usTam P 9clt.040) <br /> peglang 2PEr3too'b Phoma'm-10"I")298,4M Q Owner u Emp"(p 13 SwAce'rgannuan <br /> Intemonai COOO C;ountil rArIMpallono.- 82605gg4jC Opbraw w Thira PAIrly <br /> ALTORMATC-j(apffaiM2 irmation Date:4SM&a010 <br /> Oesi22men L)P=W-9 Narne.NIKKI KIRBy <br /> Business Name Uf dilbront fmm above):UST WW Rotation to UST 17siollfly(011@ck one) <br /> 00 Mated Operators Phone 0',(630)206.4949 Q owner a EmPloyea 0 SWCO Tachnia-21n <br /> IntornAmal Cttdo Count,Oofti6wtlon 4P i a0'J&K'q.UC 17 Oporaibi` R TWO ftrty <br /> A0 CKNATE 2 Mpffbnao ExxEairitBOR Date:M301 0 <br /> D08lonsted Opamtorla Name,JA.$0N KIRBy Relation 1)37°F/AMItV(Ch <br /> 13W'r'&33 NB(Jf different%M above),Ufff�&nX PC*0176! <br /> Oftonated opaNtor-s phone#; Q Owner <br /> International God bl's Phone - 2684M E�Enl)*" E3 Satvlm Technlman <br /> Council CartifleRflon X T*d Party <br /> ALTmERNA ropmoo Iratbn Date.0glogjaw <br /> Derignated 0pQr'qtQr'% <br /> 8vsihQ*4 Nam® if ciiffarant Aram Mcalilty ok one) <br /> Clegignatad C)Paratorin Phonp#: after <br /> interrmtolat Code Ommit 0001flootlan#! -'�*rvioa T-Donjola, <br /> Q OPe-Wr--M Third Party <br /> NOTE:THE LOCAL REGULA EXPIretbri rmta- <br /> MTHIN 30 DAYS OF THM"AGENOY"U"OR NOTIFIED OF ANY c"ANIXES 7-0 TIqAt <br /> C"ANOR. <br /> certify that,for the facility IndfCated at the tp of <br /> wlv$R6 Dei %MtedT Operator; this pago,the irIdWL1ftJ(&)IiStft abova jyjjj <br /> moflity U$ atpr(s).The indIviowl(S)WW <br /> IngRGOVOns and;R11rjUal facility arrooyee cQndL'ct and dccliment monthly <br /> Requlajjc,.*,till,2,3,Sftdon 2716 ccard"nae With C�81!fMfB Code of <br /> FurIARI'MOre,I uncle miandand <br /> (sajuge3, <br /> reguaticn4l,And Otdinstn <br /> in Q*mPMnc*with the mqulramerft"'�";1pp"C"f0 Underground stDreg,Imaks. <br /> NAME OF TANK OWNER <br /> OR OWNER%AGENT(pilaage Print) <br /> A-) <br /> 1A <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AQFNT! <br /> DATE- 0 CZ <br /> ................ OWNER'S PHONE <br />