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12,114/2017 07:21 2094732344 MARCH LANE 76 PAGE 04/04 <br /> DESIGNATED UNDERGROUNDS <br /> TORAGETAN <br /> NOTIFICATION FORM D <br /> For use by Undoes Member Agencies or where approved by by yo Local Jairisdiction U E r� ( 4 2 017 <br /> slulhori Cited-Title 23 California Code o Re dations Z71S a <br /> A .PDF copy of this completed form must be electronically submitted via either the CalifoTni <br /> System(CERS)website or an equivalent local agency electronic reporting y �I LTH <br /> of the underground storage tank(s) or the addition.of a new Penson Performing gDe i0 a s of <br /> ins ections and/or facili Designated UST' para.or montlillyy <br /> ._ ty errtpioyce training at any facility covered by this notification. <br /> UStr ov✓Nr:R NAME CA. N.: „ <br /> UST OWNF,R PHONE NUMBER <br /> UST OWNER CONTACT NAME(Tfothcr than soleext. <br /> proprietor) UST OWNER CONTACT T)TLE(If other than Sole proprietor) <br /> REASON FOR SUB.MTTTING THIS FORM(Check One) <br /> ❑ <br /> Change of Designated UST Operator NOTTFICATION DATE(Date this fort waq prepared or lags updated) <br /> ❑ <br /> Change of UST Owner <br /> By electronically submitting a PAF copy of thin form,the UST Owner certifies that,for the facility/f9cititics identified on this <br /> form and Any additional pages in the PAF fife upload,the individuals)lusted on this form and any additional pages well serve <br /> as Designated UST Operator($),The individuals)pfil conclact and document monthly facility inspcCtiogs and facility employee <br /> trainin in accordance with California Code of Re olations,Title 23 Section 2715 c _ <br /> FACILITY NAME <br /> CEPS M or Facility ID <br /> SITF,.ADDRESS --— <br /> CITY <br /> zm CODE <br /> ❑ Check hereCA <br /> if this notification covers multiple facilities and attach a list including Facility <br /> Names.,Sit'c Addresses,and C;T3RS,I.Ds. <br /> Designated � \���RRSTO <br /> T Operators must have current''California UST S cram `G ; OPE1 <br /> (I .Each facilitymast have a1.!coat.one l�Csi Atcd UST O erAt r_I,ist�ing alternate Satio�f led�St�he gnternational Code Council <br /> PRIMARY DES1CWAM UST OPF-RATOR NAME ICC C'ERTTt KATION NUMBER eratorS iso tion!!!_ <br /> PHONE NUMBER <br /> Kris Bell 5297?93•UC <br /> ALTERNATE I DESTGNAIEDUSTOPEPATOP (4 D8)971-2445 ext. <br /> NAMF ICC CERTTFICATION NUMBER <br /> PHONE NUMBER <br /> Brian McPhEt;ley 8394903-UC <br /> AL TERNATP.2 DESIGNATED UST OPERATOR (408)971-2445 EXt. <br /> NA.ML TCC CFRTMICATION NUMBER <br /> _ PHONE NUMBER <br /> Marla Guarnelll 8158Ei71-UC <br /> A/TER.NATF 3 DESIGNATED UST OPERATOR (408)971-2445 ext. <br /> NAME ICC CFRTiFTCATTON NUMBER <br /> PHONE NUMBER <br /> Deborah Ward 8014655-UC <br /> ALTERNATE 4 DESTONATF-D UST OPERATOR (408)971-2".5 <br /> NAME TCC_ _ TCC CERTIFICATION WlvraER PRONE NUMBER <br /> Israel$antillen 8057SI1-UC — '— <br /> AI-TERNATr 5 DESIGNATED UST OPERATOR (408)971-2445 CXt. <br /> NAME ICC CERTTFICATION NUMBER <br /> PHONE NUMBER <br /> ALTERNATE 6 DESIGNATED UST OPERATOR ext. <br /> NAME ICC CERT Mv CA77QN NUMSEIi PH< NIE,, BER <br /> ext. � <br /> Arbtpt additd0na1 pgWfV containing the abmrie•itlM,ifr�trxrtation ifmore,oan ,I;ea <br /> arwW.RrAIr�G//Ge.ot.�,' t/b-Ike,-tt 1 m4J1 c.. <br /> UN•nF2 <br /> Received Time Dec. 14. 2017 4: 03PM No. 2721 <br />