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08126/2008 13: 04 77562342F2 L,.11NNEM000A Trti i SER',JE P-GE 01 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> A00-use by Unidoct Mewhvr Agawin Or were approved by yow Lacat Jurisdiction <br /> Ai9kority Caren.- Tide 23,Dfv. 3,Ch, 16 CgUfontia Corte ofReglrbtions(CCR) <br /> FACII.FrY NANF FACILnY MHONE <br /> Food !'1'1 q(-7 6ASC'b I it (2O1 ) <br /> FACILITY SITE ADDRESS CITY <br /> Z18S' ,�. �'re.�monT Sr, S'To��1D`7 <br /> REASON FOR 31J(1MfRlNp 71I1S fDR1/(C6eck0,w0 Clunbt of Dated ppeator Update of IOC Certification FapirstDate�s> <br /> . ion i <br /> PRIMARY DESIGNAT91)UST OPERATOR FUR TII FACMrry <br /> i)FSIC,NA71FV OMRATOR RAW Q` � �/ Gn f RELATION TO UST FACILiPY(Chert Aral <br /> RUCIKESS NAME(IfAF(►F.rwlfre..,r6s.r) )wrser Sd ope ❑ Emptoyce <br /> Df SKINATED OPERATOR PHONE (�S )6a�.�Z y� ext. Third-Party <br /> INTERNA'n(NVAI,CODI'_C XIW.IL CERTiWATIOW NO.: 11 � vOb33 ry E ItATION DATE! ~v <br /> ALTEIWATE 1 UMCNATM UST OPERATOR FOR THIS FACIUTY _ <br /> DBIONATED OPRATOR NAME R \TION TO UST FACILITY(¢ant Obi) <br /> 8tJSINFSS NAME(IrAipereav fiwa ah vej: M ( ❑ Opeawor ❑ Employee <br /> DESIGNATTDOMAYOR PHONE E �[t E Seri-Tmhniclan ❑ Third-Party <br /> I NTERNATiONAt.COM COUNCIL CERTIFICATION NO.: E: I RATION DATE <br /> ALTERNATE z DtlM(21ATED UST OPERATOR FOR TALE FACIL.iTY(OW*m& <br /> i1ESIGNATtiD OPERATOR NAME: XI I ATION TO US'r FACILITY(Ckeet <br /> BUSINESS NAME(ff4t1ift+r(rm a6ww)-. El o-rw ❑ Operator ❑ E-noJoyea <br /> DESiONATVDOPE'RATOR PHONE: ( ) CXL Cl :SemmTedmi6m ❑ Third-P1vly <br /> INTERNATIONAi.CODE COUNCIL CERTIF(CAT"NO. FJ "11ON DATE.: <br /> ALTERNATE 3 OWSK34ATM UST OPERATOR FOR THIS FACILITY t601iveffo <br /> DFSiGNATED OPERATOR NAME= R1 i 1TION TO UST FACILn-Y(CA—*OU.cf <br /> BOSIMNS NAME(ffdh rtwfrw abe+er E o,,m Q omsita ❑ &wl-y- <br /> DESIGNATLD CWERATOR M40NE: ( ) ext. E .icrv=Tcclwacua Q Third-P,vty <br /> IN 1761MATiONAL(OOE COUNCII_CFATIF1CATION MO-: - 01 RATION OATS: <br /> I certify that, for the fteel7ity indicated at tilt top of this page, the individual(s) list'I tbove will serve b Designated UST <br /> Operator(s). The ladhidwal(s)wfll torlduet and doe.meat nsotMMy NaHty inspection ,rad anneal factlty employee training <br /> in accotdttace with Californisl Cale of Repladens,Title 23,Section 271S(e)throeEb("I Fortliermort,I naderatand and am <br /> in compliance with the regairements(ihtutes,replations,and local ordiMUCCS)VPBV I Ie to underground storage tanks. <br /> TANK OWER NAME: ,L7 P/2 1- 41 — . <br /> rANIC OWNER TITILL awry 1 ?t PHONE: ( `20l) S (1`1 1 1'1 0 0 <br /> TANK OVI/NFR SIGNATURE: DAT: � 5 8 <br /> INS RUCtIO14S <br /> I- Report tht name(s)of the Desiguatcd USf Operator(s)as registered with the intetnation I Code Connell(ICC). [CC certification <br /> information is available on-line at:www-emit org/dcertasarelr hhmL Search for-Calif I iia UST Systcm -" <br /> 2. Submit this completed form to the local agency that regulates this facility's USD3. Wj iocs member agency jurisdictions and <br /> contact information are listed on-line at: www.auidomergtmemberV-borepttteswl' t-btmi Contact information for other <br /> local agencies within California is available at:www.swrtb.ca<goKewPho+ndnstlmntacl'I iecsAoeat_agency_list.als. <br /> 3. 23 CCR§2715(a)requites that you notify the toot agency of any changes to this informat i i within 30 days of the date of change. <br /> UN-062-1n www.o&w4C% t D9/nms <br />