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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name!Facility <br />14 1 1 F- <br />ID <br />Facility Address! ®Du_4 (—:=7- <br />S-k06-k:Tn-Q,r�-A G�t�-I? <br />Reason for Submitting this Form (Check ont;) <br />M Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone C _7L/ <br />0- ♦ . .6 - Qxrow,102i'0110 <br />PRIMARY <br />Designated Operator's Name: RANDALL KIRBY <br />Relation to UST Facility (Check one) <br />EI Owner El Fmpfoyee C SGNIra TeCkn]Clan <br />0 Operator E Third Party I o <br />Business Name (if different from above). USTanx <br />Daslgn2ted Operator's Phone #: (530) 268-3949 <br />International Code Council Certification #! 6250566 -UC <br />Expiration Date: 12128/21 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: JASON KIRBY <br />Rol2tion to UST Facility (Check one) <br />El Owner D Employee F-1 Service Teo-nician <br />0 Operator E Third Party. <br />BusIness Name (if different from above): USTanx <br />Designated Operator's Phone #: (530) 268-3949 <br />International Code Council Cet-tification #: 5270158 -UC <br />Expiration Date: 10-01-2007 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Narne,,k4N*X—T+KMV1?30t4— <br />Relation to UST Faoility (Check one) <br />0 Owner F1 Employee ID Service Tec",!nicen <br />0 Operator 0 Third Party <br />Business Name (If different from above). 4k9T-VA* <br />Designated Operator's Phone # - <br />International Code Council Certification # .-5244224-W; <br />Expiration Date- 4=24200& <br />ALTERNATE 3 (Optional) <br />Designated Operators Name: <br />Relation to UST Facility (Check one) <br />0 Owner 0 Employee 0 Service Toch niclan <br />0 Operator 0 Third Party <br />Business Name (if different from above): <br />DGS19112teld --Operator's Phone #: <br />International Code Council Certification 4: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br />WITHIN 30 DAYS OF THE CHANGE, <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 individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, section 2715 (c) - (f). <br />reguations, and local ordinances) applicable to underground storage tanks. <br />i I A I 1 8 1 <br />Lai ZiLftl'ej 0 LIVIffff I raj - <br />SIGNATURE OF TANK <br />