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NOTIFICATION FORMi-�-�,v�&I--c 1, JJL� <br />For use by Unidoes Member Agencies or where approved by your Local J4kisdieridit', '-'`J' <br />Authoritv Cited: Title 23 California Code ot'Regulations §2715(a) <br />A PDF copy of this completed form must be electronically submitted via either the California Environmental Reporting <br />System (CERS) website or an equivalent local agency electronic reporting portal within 30 days of a change in ownership <br />of the underground storage tank(s) or the addition of a new person performing Designated UST Operator monthly <br />in.,mertinnq nnd/nr facility emnlovee training at anv facility covered by this notification. <br />A. UST OWNER IDENTIFICATION <br />UST OWNER NAME <br />UST OWNER PHONE NUMBER <br />Anabi Real Estate Dev., LLC <br />(909) 394-4728 ext. <br />UST OWNER CONTACT NAME (if other than sole proprietor) <br />UST OWNER CONTACT TITLE (if other than sole proprietor) <br />Summer Ireifej <br />Controller <br />REASON FOR SUBMITTING THIS FORM (Check One) <br />NOTIFICATION DATE (Date this fonn was prepared or last updated) <br />MX Change of Designated UST OperatorON <br />October 26, 2016 <br />[j Chan ge of UST Owner <br />By electronically submitting a PDF copy of this form, the UST Owner certifies that, for the facility/facilities identified on this <br />form and any additional pages in the PDF file upload, the individual(s) listed on this form and any additional pages will serve <br />as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and facility employee <br />training in accordance with California Code of Be <br />y,ulations, Title 23, Section 2715(c) - (f). <br />B. FACILITY IDENTIFICATION <br />FACILITY NAME <br />CERS ID or Facility ID <br />See attached site list <br />SITE ADDRESS <br />CITY <br />ZIP CODE <br />Check here if this notification covers multiple facilities and attach a list including Facility Names, Site Addresses, and CERS lDs. <br />C. DESIGNATED UNDERGROUND STORAGE TANK 0PKEAjPR(a_ <br />Designated UST Operators must have current "California UST System Operator" certification from the International Code Council <br />(ICCI. Each facili!y must have at least one Desi ated UST Operator. Listing alternate Designated UST Operators isoptional. <br />PRIMARY DESIGNATED UST OPERATOR NAME ICC CERTIFICATION NUMBER PHONE NUMBER <br />Kris Bell 5297793 -UC (408) 971-2446 ext. <br />ALTERNATE I DESIGNATED UST OPERATOR ICC CERTIFICATION NUMBER PHONE NUMBER <br />NAME <br />Brian McPheeley 8394903 -UC (408) 971-2445 ext. <br />ALTERNATE 2 DESIGNATED UST OPERATOR ]CC CERTIFICATION NUMBER PHONE NUMBER <br />NAME <br />Maria Guamelli 8158671 -UC (408) 971-2445 ext. <br />ALTERNATE 3 DESIGNKI'ED UST OPERATOR ]CC CERTIFICATION NUMBER PHONE NUMBER <br />NAME <br />Deborah Ward 8014655 -UC (408) 971-2445 ext. <br />ALTERNATE 4 DESIGNATED UST OPERATOR ]CC CERTIFICATION NUMBER PHONE NUMBER <br />NAME <br />Israel Santillan 8057571 -UC (408) 971-2445 ext. <br />ALTERNATE 5 DESIGNATED UST OPERATOR ]CC CERTIFICATION NUMBER PHONE NUMBER <br />NAME <br />Steve Parmenter 5311561 -UG (408) 971-2445 ext. <br />ALTERNATE 6 DESIGNATED UST OPERATOR ]CC CERTIFICATION NUMBER PHONE NUMBER <br />NAME <br />I I I ext. <br />Attach additional pages) containing the above information if more alternates may be used. <br />UN -062 www.unidoes.org 1/1 - Rev. 01/04116 <br />