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12/15/2004 12:24 6613635467 DJA INSPECTION PAGE 02/04 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name. ' e 14 1— CC S7`1 %/ a/V <br />Facility ID #: <br />Facility Address: n , ^ <br />c3r-& S . NG%/� KIrG t;Iglq'F L v i)/ (f - �J � :�`�L <br />Reason for Submitting this Form (Check One) <br />❑ Chango of DesigndW operator <br />❑ Update Certificate Expiration bete <br />Fad ltyPhone #: b ' _ �/ <br />Desigasted UST Q,2201or(s) for fitful FnCility <br />WO WM ♦ ov <br />Designated Operator's Name: JOEL CRAWFORD <br />Relation to UST Faet7ity (Check OKO <br />Business Name (ff dr,ftrent from above): CHAMPION PRECISION TEMPO PVC <br />O Owner ❑ Operator ❑ Employee <br />® Service Technician ❑ Third -Party <br />Decignmed Operwoi s Phoma #: 916-927-1557 <br />International Code Council Certification M 5240664 -UC <br />Expiration Date: 08/12/06 <br />Designated Operau is Name: JEFFREY GATES <br />Relation to UST Facility (Check One) <br />(3 Owner ❑ Operator C7 Employee <br />Servkz Tedxrician ❑ Third -Party <br />Business Name (Jf Aftremt from above): CHAMPION PRECISION TESTING INC. <br />Designated Operator's Phone #: 916-927-1557 <br />Lntemational Code Council Certification #: 555497689 #.APPL ED FOR <br />Expiration Date: 11/11/06 <br />Designated Operator's Name: <br />Relation to UST Facility (C.hwk One) <br />❑ (purer ❑ Operator O Employee <br />❑ Service Technician ❑ Third -Parry <br />Business Name (If doerenr frog above): <br />Designated Operator's Plane #: <br />h ternatio nal. Code Council Certification. #: <br />Expirariop .Dew <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Operator(s). The individuals) will conduct and documerd Monthly <br />facility inspections and annual facility employee paining, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and bell ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Pkaae Print): <br />SIGNATURE OF TANK OWNER: <br />k <br />DATE: Z d �. / �-P OWNER'S PHAE 0: 2-D <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: v.,%-u.watcrboards_ca_ea-/ust/conL%-Wcpp agys.hftL <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 .DAYS <br />OF THE CHANGE. <br />November 2004 <br />