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UNDFAGROUNDSTORAGE TSATEM <br /> T <br /> OWNERSTAOF DESIGNATED USTOPERA <br /> UNDERSTANDING Off'AND COMPLMNCE VVIrM UST Q <br /> For use by Un dow MeW or Agenda or w1mve qqvrowd byyo'Lwd Jurisdiction <br /> Autho?*y Cited. 7711e 3,Div. 3 t"h. 16 f a fifamia Code of A aularudw(CCR) <br /> FACILUTY NAME FACILITY PHONE <br /> Kwik Serve (209)832-1810 <br /> ' <br /> CrlY P' <br /> r•ACII.ITY Siff ADDRESS <br /> 850 W. 11ll St. Tr2CY ,r^�` <br /> REASON FOR SUSMI'1-t-ING THIS FORM(Check ane): Change of Designated Operator ® Update of ICC Certification E3Mkk&Doe(s) <br /> PRMARY DESIGNATED UST OPERATOR RTEN FAC11L <br /> ON3SIGNAT®OPERATOR NAME: James�(yQ, RELPit'tOAt TO UST FACILITY(Check One) <br /> IIUSINESSNAME(tfrt&r+ent, above); ❑ Owner ❑ Operator [I Employee <br /> DESIGNATED OPERATOR PHONE: (209)601-4641 ext, a Service Technician � Third-�9 <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO 8006067-UC EXP[RX11ON DATE: 3/17/2012 <br /> ALTERNATE 1 DESICNATED UST OPERATOR FOR THIS FACD',ITY O do ) <br /> DL'•SIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check Qrre) <br /> BUSINESS NAME(lfAferent frwa above): ❑ owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party <br /> TNTFRNATTONAT,MDR C.OIINCIL CERTIFICATION NO; EXPIRATION DATE: <br /> ALT TIS 2 DESIGNA UST 2!FMMR FOI~<TM FACELITY( <br /> 1RELATION UST FACILITY(Check Ow)' <br /> ,DESIGNATED OPERATOR NAME: <br /> {� :USINm NAME(Iftt{(far`nt fioen aboac): ® Owner ❑ operator ❑ Empl®yc c <br /> DFSIGNATRY)APPRATOR PHONF: ( } ext ❑ Service Technician ❑ I-Wrd-Party <br /> INTERNAI'tONAL coDG COUNCIL CERTIFICA'rI.ON NO: EXPIRATION DATE: <br /> ALT ATE 3 DESIGNATED UST OPERATQP.FOR THIS FAC TY <br /> DESIGNATED OPERATORNAME: RELATION TO UST FACILITY(Chad Ow) <br /> Bt51hrP-10,91SAMF(IfdjV;m0ArfMMahavg): ❑ Owner n Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ T'hird-Party <br /> INTERNA'rIONALCODE C04}NClLCHRTINCATIONR ; VWNRATION DATE- <br /> I certify that, for the fiwilUy indicated at the toll of the paM am ' s) bsted above Will Serve as Desiga&ted UST <br /> 01per(s). Tke IndwidaWS)wig coaMuct SO d aocnment month4r Maculty juspectiew MW unuoud AwAty em <br /> in amnbinAm with California Code o Section 27E5(e)Owafth(f). I uVidersUnd=d am <br /> in emplianee with the reqnts( u n:,and local )applicable to underground storage <br /> T O NAME: '` <br /> WANK OWNER TITLE: o W OWNER PHONE: <br /> TAMC OWNER SIGMA DATE: <br /> INSTRU ONS <br /> 1. Report the name(4)of the UST s)as registered with the Inteimabonal Code Coamil(ICC).ICC cerdfication <br /> m 'on is le online at: a org/e% tmL Search for" • UST ." <br /> ? . this leted to the that regautes this " -s UKI-s. Uafdoas member agency yuris . and <br /> conma infmnhan are lisited on-line at: .Unido memberstwhoreg tmi. ContrA information for other <br /> local aasmc=within Cgilimm is available aL wwwjwmbmmovjcwphemciiLWtonbdddocAoCW,. <br /> 3. 23 CCR§2715(a)requirm dW you not*the IDW agency of any dmgm to 30 days of the date of <br /> TO 39dd 3A83SAIMA z90ZZ686OZ 6T:00 01OZ/8T/EO <br />