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01/11/2005 12:29 9169277344 <br />CHAMPION PT INC <br />ot./04/2005 10:47 FAX -- - <br />_� 01/04/2605 3.5:11 8369277324 "Mpim PT IRC <br />'-_ <br />Owner S tenjrrits of Desi, med Underground Storage TCUS i) OPerptor <br />and 1_ nders�dll'l.g of and Complic"ce watts UST Requilx�nyenfs <br />Pasliity Nin. ( �.' ✓ .* ,,y <br />Faculty 71) it, Ln 0 Y <br />r7- 120 Rortyon Eor 5uhtniaxtnz this laorrrt K7aeck One) <br />FAcility Addt 't) 3 Ci ® ❑ Charm of Uasignated OrANOGr <br />Sp UpdlateCwdficalaex an Date <br />Rmsignatcd Op�reat�r's lvartaas: — L t. <br />I3u�icaesl�lsms (If./ljjer•mrU fFaae ctlidva): wa <br />Dcsi�.tdd Operator's phemc �: � f <br />Irrtetaattann; Codc Couromi certification N:,r .2 Al p <br />D'gignmed E antot'sNrenac �v! : B <br />susinmNow <br />ffjd(�awnrfroma6�) � <br />13esignatxd OPefrlyS phapc k: i i . <br />IgternatiDnei Cede Council Ccrtifi=604 nt <br />ALT1ZPdA'CE I �rr�,iopar) <br />-taylgMtW4 OPOMcr9s Ne: T <br />g teincs5 NtMtfe ((tdlfleraaru a airaNa), <br />fj'zjyAtad opoffitwe 1Pwnc tri. <br />inDmtdtlooW Code Council C %111cad®e <br />Lwupwialt <br />Lo UST rwIIitX (Check OrRB) <br />sar j3 ope or ❑ E"PImra: <br />ea !'acltnicaan ❑ 'i'lmtd.PmV <br />Unto 8' - I A - Q p— _ <br />oa> m UST Fa dl ty (Check Oee) <br />p; i7 d�sna� r.1 c� Ertsployrx <br />or <br />ServiraTechsticimt Gi .Ttlird�Perty <br />�. F,xpirattion T�atG <br />itelatlon m (IST rSVi ltty (chdik 0* <br />1`3 O=cr ❑ Openetttr ® Faltploy= <br />gr <br />g�v/'�}tltlninn P ThiCtl+PtUtY <br />9% ° float �1ai 'd 1 • i, <br />I CC tfy tilt, for the facility ilb lcatcsi at ft tole of tbi,a pap., the indMiaual(s) HOW abevc well <br />serve as Designer UST OpwAor(s). The individuad(s) will conduct and dwUntaW tzlontbly <br />.facility impectiions and =mW iFacil3ty emplOxee ftiniing, in gwoldmce witb,California Coda of <br />Regulations. title 23, secdoa 2715(c) - (f). <br />parthemore, I qudiarstand and am in co !Donee witdl tie regiudromentsOtatutes, <br />regu!minas, and XBegl ordinam ) appkdcaable to undo and Storage tan , <br />i OF TANK OWMR(Pkme +6- - _ti 40 •+�.. <br />DATE:sle.NATURE OF TANK OWNER; <br />N43T>m: t> 9URM1T T" is COMPLZTED MRM TO THL LOCAL AGSINCY (NOT THE S'T'ATE WATER <br />,RESOURCKS CON' 909 BOARD) BY JANUARY I, 2005. THE I.rOCAL A rsENCY LIST IS AVAILABLE <br />AT., www ���Choards s�,A*.SLvhi aon�tt cu�� <br />21 NCrrrR'y Tilt LOCAL AGENCY OR ANY CEIANGIS TO TlIIiS I(, IZORMATION 1iVi MIN 39 DAYS <br />Cif THE 'CRAB!,. <br />November 2004 <br />