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Sep 09 05 09:38a USTa-x 530268Q330 p.2 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: -- C, R P <br />Facility 10 #: FA 0c)(no 3 9 a 5 <br />Facft Address: o -1eason <br />R for Submilting this Form (Check one) <br />0 Change of Designated Operator <br />0 Update Certificate Expiration Date <br />Facility Phone# - '5R,9 9 43 — E, (P <br />Designated UST 0joeratodsLfer this Facilgy <br />i� <br />Designated Operatne- Nam,-- IAN;NF K!RRY <br />Rdabor to UST Facli1y (Check one) <br />0 Owner 0 Employee 0 service Technician <br />In Operator V Third Party <br />Business Name (if different <br />Designated A Phanp ?68-3"9 <br />international Cade Council Certification #: 52"224.UC <br />I Expiration Date: 10102121106 <br />ALtF-KmATF- i (®phonal <br />Designated 0 Name RANDALL K1 <br />Relation to UST Facility (Check one) <br />0 Owner 0 Emplol <br />yee 0 SeMceTechnician <br />0 Operator M Third Party <br />Business Nwft (if different from above): <br />Designated Operator's Phone #: (530) 268-3949 <br />International Code Council Certification #: 525 <br />Expiration Date: 1212812006 <br />Designated Operator's Name: TERESA KIRBY <br />Relation to UST Facility (Check one) <br />0 Owner 0 Employee 0 Service Technician <br />L3 Operator M Thad Party <br />Business Marne (if difillanwt.frorn above): '-.' --,. ..a <br />Designated Operator's Phone*: (S30) 268-3%9 <br />j <br />International Code Council Certification #: 52445074JC <br />Expiration Date: 1012312006 <br />ou. a =xmvft i r- a ( upaionay <br />- Operator's Nam. JASON KiRBY ieabfw to UST Facility (Check one) <br />Business Nome (if clifferent from ab.,,-): - 0 Owner 0 Employee 0 Serwice Technician <br />!Designated Operator's Phone#: (530) 268-3949 0 Operator fill Third Party <br />International Code Council Certification # - pending <br />L -... Expiration Date: <br />ALTMNATEM Modea.11 <br />.......... <br />7 1 <br />M, TV41 <br />FuraaineM x wudenftnd &" an im e*mp"Oft WiS *0 nR*hM=Mb (sftftftl� <br />a 99WktbP&%, and bxW orAkmixa) applillimble to andowgromW sammp tmtkL <br />NAME OF TAM OWNERn"M <br />MCNATURE OF-.- <br />PATIL IMMIRISIORONE 0. <br />Nammber 2M <br />............... <br />.......... <br />7 1 <br />M, TV41 <br />FuraaineM x wudenftnd &" an im e*mp"Oft WiS *0 nR*hM=Mb (sftftftl� <br />a 99WktbP&%, and bxW orAkmixa) applillimble to andowgromW sammp tmtkL <br />NAME OF TAM OWNERn"M <br />MCNATURE OF-.- <br />PATIL IMMIRISIORONE 0. <br />Nammber 2M <br />