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01/04/2010 14:00 2.09.3697S# WINE GUUNTRY STA PAGE al <br /> ...... -... <br /> UNDERGROUND STORACIE TANY% SYSTEM FRSTANDING <br /> OWl,SX STATEMENTS OF DESYGNATEp UST OPERATOR � <br /> OE AND COM LLWCE %ITIT UST REQ <br /> • Authority Cired: 7Yt1e 39, <br /> biu 9, Ch. 16 Caltfarnla Codd CfROJ?Ulattom(CCI <br /> PAC(/LtTYPI{ONS <br /> �L <br /> Q �7 4 <br /> FACILITY NAMGn C� �"Q.C-© A'i11 )Y✓� l ZO�1'� <br /> 1� 1�.I1Y 1 <br /> FAC[LTrY SITE ADDRL°SS 9$•2+) S TD C-g-7— )"- <br /> R S� S, SID' z fl�Ul'•C � !, 7R)L�+IUr U}� <br /> RE SON FOR SU3 0 THIS PORIA(Check Ono; Change 'i 5sipared Operrit0r Update of ICC CcrtiFcutiea P,>pirntian Y7 'n.x(s) <br /> ,PRIIVUAY DESIGNATED UST OPERATii)R Felt TIIl s FAC1LJ' RELAT1pN TO rJST FACILITY(0=00mJ <br /> DESIGNATE�DOPEIL�ATORNAME,:Cy� �, pwnw © Operator © Employee <br /> BUSitlEssiJAME(Ue u ;� ' ❑ ServineTcchaielan [ Third-Party <br /> DESLONATEDOPERATORPHONE: f, �3% - r}.3'�'O NLt, EXPIRATIOS` u, ,/ <br /> / N DATE: , <br /> IN TlONAL CODE COUNCIL CERTIFICATION ND.:S�i••• LG ° - <br /> ALTEf1tN91•L•Y-DESIST QPIlRATOR•TiOR"1'TiIS E'ACIIJIT'ir 0 +Iona!)I'll TION TO UST FAC (ChuckOnx) <br /> DESIGNATE7OPERATOItNAlAE; 0 Owner ❑ Opgrvor © Employee <br /> 3USrNESSNQ1vE%Wditginnffropchayo; �' Third-Party I ScrYice Teetmician <br /> D10,816NATP..D OPP.RATOR'FWO'NE„ Sl(p •7/ „ ;j> Errt• <br /> TNTBRT.ATIONAL CODE OAUNCIL C.5'RT1FiCpTI0NN0_:f- . 3 ��•I _ <br /> EXPYRAT[ON DATE; <br /> AITERNA9'E 2 DESIGNATED UST OPERATOR RORTE is BACILITY(OPRELATION TO UST FACILITY(Check 0-) <br /> DESIGNATED OPERATCRNA.MB: t; ,tom, ,� \I t'"� <br /> owner3USINESSNAME(IJdif(erenfhwma ve); S.Njo © Oanr+wr [� Employee <br /> 1 �; ��.'-rz-� •. �� � ` [J Snrvlce Technician Thixl.Party <br /> DESIGNA'T`ED OPERATOR P13ONE: c• �, "" ., n �,} ext. <br /> TfONDATE: <br /> S <br /> INTEr0.A:1` :4 <br /> IANLCODE COUNCdGCER`11I'iCA7'IONNO.:' 1:7CP112A <br /> ALTERNALTZ DEiUST OPI;l.ATOR FOR':Tlii5 FACII.YJ'Y(O donOV TO UST FACILITY(Check 4nc) <br /> DPSIGNATED'OPERATORNAb M' <br /> I.WESSNAMEtIfdff villffdNQbOYe): Q server © iglan or © Employee <br /> BUS <br /> © ServiceTeahrriolan © Third-Party <br /> DESIGNATED OPERATOR PHARE: ( tKt. <br /> LiJCFIRATiCN DATE: <br /> INTERNATIONAL CODE COGNCIL CSIMPICATION NO.: <br /> • <br /> I Certify that, for the,facility indicated at the top of tllis page,the individuals) listed above will serve as Designated IIS' <br /> Operator(s). The individual(P) will conduct and document monthly facility Inapectious and <br /> Unocal <br /> rjacUity understate training <br /> am <br /> In-aecordanec'rrith California Code of Regulations,Titic 23,Section 2715(0)through(A• <br /> 4o tompliauce with the raqulrencnts'(atatute$,regulations,and local ordinances)applicable to underground storage tuOks, <br /> TA:XOWNERNANILr E E 1 V6!Mf_YLI <br /> TANK O WNEX TITLE; 6- I t�-I V t�51 1 M u N 7 i Lu C)WNER PxONE; ! 29 �6r�i LI 0 <br /> TANK OWNED.SIGNATURE: <br /> DATE:— <br /> lN5't'RYICTI_( 1 <br /> L. Report the namo(al to the Designated toheY t15T OperCounty nva n registered with the International Code Council([CC). <br /> Z. Submit dais completed form t0 the County T:nvirottmcnml Health>:lepardvrcnr via mail: 197 N. Cottonwood SL, Suite 2400; <br /> Woodland,CA 95695,via email:c^"irpurnenlaa hW_IIt[[a)vigLocountV-o or via fix;(530)66$-1448 <br /> 3. 23 CCR.§2715(a)requires that YOU aaify the local agency of arty changea'to this information within 30 days of the deie of change. <br /> . (IPCircdr S/a7 <br />