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UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Dir:dor_r Mmubar Agowies or wkere approved by your Local Jurisdiction <br /> Au(hority Chad• tide 23,Div.3,CA. 16 California Code of Regrrlotiau(CCR) <br /> FACIL"NAME FAMITY PHONF, <br /> road /)1qr7- &as0hY' e (261m ) '591_t'_)00 <br /> FACILITY SITE ADDRESS ( w <br /> j-, IV.1 � <br /> REASON FOit St BMI'1'PING 11115 FORM(Cheri O=0: 10 Change of Desigrmtad Operator Update of ICC Cettiftcatien Expiration[Wr(s) M_1 <br /> PRIMARY DESIGNATED LIST OPERATOR FOR THIS FACILL'LY <br /> DESIGNATED OPPRATOR NAPE: .70 1 n do f L A 1 RELATION TO UST FACILITY(ChcrA Cis) <br /> RUSINItS NAME(/f&WiWys--how): � Owner ❑ opt-w,, ❑ Entpioyee <br /> DESIGNATED OPERATOR P"E: (77 5)(57:�-S-J,yY ext. ❑ Spice Teciwld>m ❑ Third-Party <br /> IN"I'ERNAnONAL CODE CamCILCsRTIFEATION NO.- FR adO �gc! EXPIRATION UAn_ <br /> ALTERNATE I DMGNATED UST CMUTOR FUR TW FAC1L[TY <br /> DESIGNATED OPERATOR NAME RLLATION TO USI'FAaL(Y(Gift*000) <br /> BUSINESS NAME(fAAVm!W.l*wa&wr : ❑ Owner ❑ operator ❑ frnployee <br /> DESIGNATED OPERATOR PWN> ) ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(GI}anrrl) <br /> DESIGNATED OPERATOR NAME RELATION TO LIST FACULTY(Cicsc4 airi <br /> BUSINtMS NAME(fAW6*&V)hw db&K): ❑ 0+►w ❑ Op mot ❑ Em*YL, <br /> DE-SIGNAII:D 01184ATOR PRONE:: ( ) czt. ❑ SctYioc Todmicm ❑ Third-Parly <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO_: EXPIRATION DATE.: <br /> ALTERNATE 3 DESIGNATED[,IST'OPERATOR FOR TIM FACH ITY(15ladmam0 <br /> UF-SIONATED OF"CRATUn NAME: RFIATION TO UST FA(`IIa1Y(C*mA O..r) <br /> BUSINM NAME((f/i(JnaN eho+�; ❑ Owner ❑ Oparator ❑ Employee <br /> LASIGNATED OrMATIOR PHONES ( ) ext. ❑ Setvioe Txia>,ciao ❑ Third-Party <br /> INTERNATIONAL(-'ODE COUNCIL CFXTtFiCATNM : EXPIRATION DATE: <br /> I certify that, for the facility istdscat{ed at the tap of this pate, the indi.id■al(s) listed above will serve as Designated UST <br /> Operator(s). The(rdividaal(s)will conduct stat+dec.uaat molt*favi ty istapeetimu and aaawal fac3ty empkayat training <br /> in accordaaer with California Code of Re6alifitas.Title 23,Sectima 2715(c)dwoogh(0- Fardmwos we,I ualerstaad and alt► <br /> in compliance with the retleivenamts(statwtes,rnuiiatiom,and load ordilean=)ay ptscabie to awdegWound storage(auks. <br /> TANK OWNER NAME: -:5-6 fir, 1 ,&-! 6 41 <br /> TANK OWNER TITLE: OWNER PHONE: r7 <br /> TANK OWNER SIGNATURE A ` ca_-1DATE: � 2--,5 / ate_ <br /> uY�noxs <br /> I. Report thc rtatrtc(s)of the iksiglated UST Operator(s)as rcpjstaed with the Intonational Cade t ouncil(ICC), ICL'certification <br /> infortnation is available on-line at:www irrsatc.OrWelawtieuch,htmL Srardt for"California UST System Operators.- <br /> 2. Submit this complracd form to the local agency that regulates this far lily's USTS. Unidocs member agemy jurisdictiotu anti <br /> contact information art listed on-line at: art+w.rteadOes.otr�loemberyarltptegplsteswbst L CORtaet infarmattotl fol other <br /> local agencies within California is available at:www swretLen Rov! docsrocal_agcstcy_iitt xh. <br /> 3, 23 CCR§2715(x)requires that you notify tete Local agency of any changes to this information within 30 days of the date of change. <br /> VN-"Z-1/1 ...n►.oniaaesma 09n2105 <br /> Be 39Cd 3[,,a3S ,'"l vDont,V3N1qTM ZSZVEZ95LL c0 :0i 80aZ/9Z/80 <br />