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Owner Statements of Designated Underground Storage Tank (UST) Operaior and Understanding of and Compliance with UST Requirements F3citity Name: 49,0 Ct c Jt C- -'1 aplity ID acifityAddress. p106 S, C F� Reason for Submitting this Form (Check one) L Change of Designated Operator Faclity Phone #: ❑(5 ? C! Updatfi e Certtficate Expireon Date Desi mated UST O erato s PRIMA13Y fdr this Facilit FDesigDesignatedOwator's Name: JANINI< ICiRBY ness Name (If different from above): USTanx Designated O2°rator-s Phone # : (530) 268-3949 Intemationai Code Council Gertrycatiorl # : 5244224-uC ALTERNATE t (Opuonaf) Designated Operator's Name; RANDALL KIRBY Business Name {lf different from above): USTanx Designated Operators Phone # ; (530) 268.3949 International Code Council Certification # : 52$0566_UC ALTERNATE 2 (Option j) �De,sjgnated Opardtors tvame; TERESA KIRBY iness Name (if different from above): USTanx Designated Operator'$ Phone # ; (530) 268-3949 tnteriiationai Code Council CerUftcatjon ffi : 5244507 -UC ALTERNATE 3 (On>fonan Relation to UST Facility (Check one) ❑ Owner ❑ Employee ❑ Service Technician ❑ Operator 9 Third Party Expiration Date: IOIO 2006 Relation to UST Facility (Check one) ❑ Owner D Emptovse O Service Technician D Operator a Third Party Expiration Date: 12/2812006 Relation to UST Facility (Check ane) 0 Owner D Employee D Service Technician ❑ Operator A Third Party Expiration Date: 10/23/2006 �pt'CIOf� [Designated Opsr3ta S Name: JASON KIRBY Business Name (If different from above)- jiSTarax ;;It,-F1a010112 ST cility (Check ons)❑ EmPtoyee ❑ Service TechnicianDesignated Operas Pi(530) 268-3949 1G T11ird PerryIn emaronai Code Council Cerufira;lon 52701g$ -UC 007 NOTE; THE LOCAL REGULATORY AGENCY MU$T BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE_ I certify that for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Pegulaticns, title 23, section 2715 (c) - (f). Furthermore. I understarnd and am in compliance with the requirements (statutes, reguations, and focal ordinances) applicable to underground storage tanks, NAME OF TANK OWNER OR OWNER'S AGENT (Please Print): SIGNATURE OF TANK OWNER OR OWNER'S AGENT: DATE: OWNER"s PHONE 4: