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Owner Statements of Designated Underground Storage Tank (033) bperatur <br />and Ina"tanding of and Gampliance with UST Requirements <br />Fae�i y Hama � ,.r FeaAty ID 0 <br />F 3 IRy Adtlre6s: C1,7C z.. C 4,-r k � Lx',,L . Remor. fc. Subn� thk For. (r,..tme <br />r.har:o of t3"nat,Rd OperaW <br />FBpIH y Ph o # a.pG� , FS 67 —9S4.0 Update Cettic*e ExplrMloP: <br />DeC- <br />Ddaipnaiad Qpwmt&m nwn JAiNINM KI BY <br />Business !dams (tr d"kfem trona aN e): i.1STarm <br />DsltpmaW ODera= Phom 9: (S3U) <br />II t�ereaiionsE Corte GGL�c t GmtbF:edtur, C : 62442244JC <br />ALTERNATE 1 (OpUaw j <br />iQ7 Q'p--�*ft Name: RANDALL K>PAY <br />atminm Name (if dv%;M t time 49bow): USTjtrx <br />ENWgnsted opsnmoev Rnano �ratA 6t3.i _ _ <br />intemsftnffi Cod* CounaJ C4tl�ibstivn # 6'a645�(r iiL <br />ALTER ATE 2 (Qr➢tfnnaf) <br />0409ga d Cf4a Wa Memo; TERESA KIRBY <br />business Name (if d%rerrt fiu,# #buve): USTam <br />i}zsgrrs d Opexatass I'horie : (5` 0) 26$-3949 <br />InWnational Cade COMO CWJftCn R 0 : $244607.UC <br />ALTERNATE a (0prsonsq <br />Dish Qpwawrla Marr;; .aA" ICY <br />�Bralr aw. ?+kwrva ff;i� from 'a&w): US -4 3'nx <br />D-ignow Qperaws Fhohe* (530) 2664949 <br />1n*mtz6anvi Cade 0Ct.-Tvwi ^.oMtj*tion #: oendq <br />toris-) for this Faci i <br />°tei-6an to UST Facility (Check, c") <br />0 + Q � t7 $er axTe�imiCQi1 <br />0 Operetor M ThH Perry <br />E*'*Oor Dwt-.: i si -2m <br />RcWm to UaT Fad (Check one) <br />Q Owner U Lir ougee Q $grnim Technieisn <br />Q Opereter E Th(W Party <br />Rs�&*I- to tJST FaMky (Chsc r ono) --- <br />C, Aruna G i�mp -') SwAceTftNdcin <br />© C?p¢.M* 0 Third Psrty <br />Rew.on to UST "=Ay. (cr y) <br />0 0~ 0 EmPIgy a ❑ Setvne Tech^ictn <br />C OpwMar 0 Third Pariq <br />F-Vyff am DO* <br />No T E: THE LOCAL REGUWOR Y AGENCY MUOT Se NOTIFiND QF ANY CHANGES TOTHM iNPQRMATjoy <br />WWTKN $0 1,3AYS OF THE CMANgE. <br />I t rOY that kr Vte f�"rty irx� atSd at the tap of oris page, the :ndjyldUei(S) 33ted above w?t <br />ferva as Le60raWd UST Opemtor(s)_ The indKiduaks) aoil conesuCg and doo vment monNy <br />facility i%Pecz1Pr?$ aRg annual faCii►y employee tMiNng, ih a=rdence wrh Canfarnla Cotte Lf <br />ftegulaWrws, ting 23. sec :,or, 2713 (c) .. (i . <br />Furthermore, I urKi"€and and Ara in ronnpliance v"th &10 reglirensr (gjat"k:§, <br />reguRbOM arnd kaOW Qrlr amw) livable to underground s4nragm tank;, <br />NAME OF TAW OWNER <br />OR OWNI R 4 AGENT (PtwAo Print) ; <br />SIGNATURE OF TANK <br />Eg"EROROWNERS AOEXT: <br />