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E <br /> CE.," ED <br /> DESIGNATED U"ERGROUND STORAGE TANK OFfI14T91tR <br /> NOTMCATION FORM <br /> For use by L'nidoas Mmber Age)reia or where opprol*a by your Local JartR <br /> Author• ,GlcA" Title 23 Cal' nia Code o Rc rlatIOW " "1 Sia <br /> ltd t�{ § <br /> 1III= <br /> 111,11p,11111,11 <br /> A PDF copy of this completed farm must be electronically submitted via either the California Enviro ' =na ng <br /> System(CF.RS)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 /> inspections and/or facility employee at an facift covered by this notification. <br /> A. UST OWNEREN FIC T <br /> USTOWNI:iCt NANIZ UST OWNF.RMONENUMBER <br /> MCI dba Verizon Buiness 909-879-2712 ext, <br /> UST OWNrA CONTACT WIE(If otk-r than We proprietor) LIST OWNER CONTACT TCTLF.I If other than sok proprietor) <br /> Zachary D.Feingold Envirownental Manager <br /> REAWN l t)R SU BMITMG 11RS rORM(Cheek Ung l N'trl'IFIt:NITON 0,(%TE(I)etc this form was prup"or lost updated <br /> Change ofDcsignated UST operlltor August 22,20i7 <br /> Chan of UST Owner <br /> By electronically submitting a PDF copy of this form,the UST Owner cert es that,for the faeitity/facilities Weadfled on this <br /> form and nay additional pages in the PDF file upload,the indivWuni(s)listed on this form and any additional pages will serve <br /> as Dalgnated VST Operataros The individual(s)will condaetand document monthly facility inspections and facility employee <br /> traluia kin accardanes with California Code of Regulations.Title 23,Section 2715(c) ft <br /> - <br /> B. FACILITY IDENTIFICATION <br /> _ <br /> FACILITY NAARE C;I RS ID or Facllity In <br /> SrrE ADDRESS <br /> -- 7.17 CODs <br /> C/A <br /> My <br /> Check here if this notification covers multiple facilities and attach a list including Facility Names,Site Addresses,and CRR3 IDs. <br /> C. DESIGNATED iV RG UN ST C.EANYOPERATOR <br /> Des d UST(Verutors must have curteRt"California Mr System "ccrtiflcatlon from die lntarnatlonal Code Council <br /> 1C .EaCh7fliCilitY mast have at le"one Des -USTCppermor.Listfuniaditernate gpotedUSTgReramlsoggonal. <br /> PRIMARY DE:SICINMED UST OPF;RATCIR,NAME Ice C ERMCAMN MINIM Ft PHrNE NUMBER <br /> Leonardo Aguilar 5302718 (88 588-8737 <br /> ALTERNATE t DESIGNATHI3 UST OPERATOR ICC Cii'R'rwicxrtoN Ntisinfm PHO**F%411111117 <br /> �:ANn3 <br /> Ruben Becerra 5302139 (8981588-8737 ext. <br /> 1 MIRNNW.2 lxi slc;Nn cru UST()PF.RA.It)R ICC CERTIFICAITON NUMBER tmUWNlMM <br /> NAI.Ap <br /> David Branson 8026749 (888)588-8737 ext. <br /> , fURNSTE 3 I311SIGNjYM-D UST OPERNFOR <br /> [CC CfRTIk'1C.1'IWN NUMBER PHO"N'E\R MIER <br /> NAME <br /> Todd Hansen 8045710 (888)588-8737 s xt. <br /> ALTFICNATE41)SI;NATEDIT9-1 iRATOR ICCCEWnFICNrIONNUMBIAt PHONE NUMIJER <br /> NANO: <br /> Kraig Kinder 8296393 (888)588-8737 Lxt. <br /> rCLTERN.6'fE 5 DESlONWrED ISTOPF..RNITA ICC CERTIFIC:A,nON NUM111'R 1440NE NiUM1117R <br /> NAM <br /> Spencer Kissick 8169987 (888)5SM737 ext. <br /> ALTERNATE 6i)ESIONA'I'I:UUS`rUI'I:Iun-oR I.C:CCERTIIICA'130NNIiA9M PIKALMIMBEA <br /> NAME <br /> Ken Withee 8252648 (888)588-8737 ext. <br /> ,4etach additicinal pages)containing the a&, ir{Jorm irm if nitw,-utternutes inuv be used <br /> UN4162 "u munidamorg Ili-Ro.0114VI6 <br />