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01/27/2010 17: 55 2093697813 WINE COUNTRY STATION PAGE 04 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING <br /> OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> Authority Cited: Title 33, Div. 3, Ch. 16 California Code ofRegulattom(CCR) <br /> FACILITY NAME PACILITY PHONE <br /> WH "cam �-AA )P"^ '( zbci ) � �$ ' 2-11 <br /> FACILITY SITE ADDRESS CITY <br /> �gSS S Slate Soule g9. c!<�Or C� 9s2�i sIDC-J:e— 7--bA <br /> REASON FOR SUI) TTING THIS PORM(Check One): Change of Designated Operator Ej Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME:` RELATION TO UST.FAOR ITY(Check ow <br /> BUSINESS NAME(1fdlg'erentfo ower _ cx E] owner C] Operator [I Employee <br /> DESIGNATED OPERATOR PHONE: ( ),3 oe0 ext. ❑ Service Technician ® Third-Party <br /> INtERNAT70NAL CODE COUNCIL CERTIFICATION NO-:4s, d �m EXPIRATION DATE: S- 2-070// <br /> ALTERN'M 3-DES'IGNATED UST OPERATOR•FOR'TIIIS FACILITY 0 tones <br /> DESIGNATED GPBRATOXNAW: RELATION TO UST FACT TY(Check'bne) <br /> BUSINESS'NAME(1fdlp"annrfiemabovx); ❑ Owner [I Operator L] Employee <br /> I)EVONAT70 OPERATORPRONE; ( 61 - _ d ext ❑ Service Technician Third-Party <br /> WERNATIONAL CODE COUNCIL CERTIFICATION�NO`�.Je- )r / - EXPIRATIONDATTI: <br /> ALTERNATE 2 DESIGNATF1)UST OPERAT611 FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: -� l' d <A RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAMB.(]fdI)Ynrenrfrorna ve): 2 A J.l-Cr.'� ' r✓_. ❑ Owner ❑ Operator Q Employee <br /> DESIGNATED OPERATOR PHONe ( c. � ) � ext. ❑ ServicoTechnician [� Third-Party <br /> INTERNATTONAL)COOB COUNCIL CERTIRCATION NO.; EXIMAATION DATE: O/I <br /> ALT X14NATE 3 DESI(5 ATED.UST OPEIATOR FORTHIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Cheek One) <br /> BUSINESS NAME(1fd( erenif dntabove); Q Owner ❑ Operator Q 9axployee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician © Third-Patty <br /> N'f BINATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> I certify that, for the.facility indicated at the top of this page, the individual($) listed above will serve as Designated UST <br /> Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance'with California Code of Regulations,Title 23,Section 2715(c)through (f). Furthermore, I understand and am <br /> in enmpliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks, <br /> TANKOWNERNAME: -- Myf-�ZlwFA4 q1 LL C— <br /> TANK OWNER TITLE: COY /1,-11/6'1 LCC OWNERPHONE: NOS )8n6-'11L4 <br /> TANK OWNER SIGNATURE: DATE: I <br /> INSTRUCTIONS <br /> 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC). <br /> 2. Submit this completed form to the Polo County Environmental Health Department via mail: 137 N. Cottonwood St, Suite 2400; <br /> Woodland,CA 95695,via email:environmental,haalth(aayizincountv.org or'via fax:(530)669-1448 <br /> 3, 23 CCR§2715(a)requires that you notify the local agency of any changes-to this information within 30 days of the date of change. <br /> Updare4:5J09 �� <br />