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16/18/2005 15:13 FAX 2097249517 TECHLANOTESTIN6 <br />y • Understanding of • Compliance with UST Requirements <br />1a003/003 <br />Facility Name:*ell;!lrk J2? <br />Facility ID 0: <br />Facility Address: <br />TJ" t7? Mb 4 C,4 <br />Reason for Submitting this Foran (Check One) <br />M Change of Dosignatcd Operator <br />O U to Certificate Expiration Date <br />Facility Phone P. 1. <br />Designated CYST Ouerator(si for this Facilfity <br />FRXNARY <br />Designated Operator's Name: B r u c e N- H o a 91 a n d Relation to UST Facility (Check one) <br />Business Name (1fdiff=ntfrvm abovaT.e c h 1 a n d T e s t i n g, I nc ❑ Owner ❑ operator 0 Emloyas <br />Designated Operator's Phone #: 4 U 9— 7 2 4 — 9 4 2 0 Ob Servioc Texlt:tician 13 Third -Party <br />international Code Council Certification 5 2 4 6 9 3 2- U C S Expiration Date: I I -19 ✓ 2 0 0 6 <br />ALT&RNATE 1 fflpdomd <br />Deaignatod Operator's Name: K e v i n M'a t 1 o c k Relation to UST Facility (Check One) <br />Business Name (ifdi ereni from abovq)rT e 1C h 1 a n d' T e s t i n I n a Owner O Operator ❑ Employee <br />Dosi is Phone #: 2 0 9— 7 2 4— 9 4 2 0 0 Service Technician ❑ Third -Party <br />International Code Council Ccrtificetioax: 5'0 6 9 8 7 4- U C Expiration Date: 0 g —1 — 2 9 96 <br />Designated Operator's Naate: <br />Reiation to UST Facility (Check One) <br />C3 Ovmer 0 Operator 0 Employee <br />O Service Technician a Third -Party <br />Business Name (1f dEfferan! from above): <br />Desigpated 's Phone 9: <br />Intcmationd Code Canncil Cextif:cation #: <br />Expiration Date: <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 trairiing, in accordange 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 local ordinances) applicable to underground storage tanks. <br />NAME OF •(Pleue,- rc ! d <br />:. moi. <br />SIGNATURE • r TANK OWNER: <br />EM,.role �q <br />og <br />0911114,161" r Cl MCW <br />• a <br />le Mr.'OTTEM <br />