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° �N�� <br /> �N�' <br /> - ' -- ---' � � <br /> ~ <br /> Owner -'-------'- -n�- g----- -----c 7 <br /> ,---- -'---p- --m,'-- `---, Operator <br /> and Understanding of and Compliance with UST Requirements <br /> ' <br /> Facility Name: 2005OCT21 )M*—.M#: <br /> Facility Address: Reason'f�r Subtrutting dus Form(Check One) <br /> Designated UST Operatoris) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Janine Kirby Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above):CHAMPION PRECISION TESTNGWC 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 530 268-3949 0 Service Technician m Third-Party <br /> International Code Council Certification#- 5244224-UC Expiration Date: 10/02/06 <br /> Desigriated Operator's Name: Randall Kirby Relation to UST Facility(Check One) <br /> Business Name(Ydifferentfrom above): CHAMPION PRECISION TESTING INC 0 Owner C1 Operator 0 Employee <br /> Designated Operator's Phone#: 530-268-3949 0 Service Technician m Third-Party <br /> International Code Council Certification#: 5250566-UC Expiration Date: 12/28/06 <br /> Designated Operator's Name:Teresa Kirby Relation to UST Facility(Check One) <br /> Business Name(Ydifferentfivm above): CHAMPION PRECISION TESTTNG INC. 0 Owner 11 Operator 0 Employee <br /> Designated Operator's Phone#: 530-268-3949 0 Service Technician E Tbird-Party <br /> international Code Council Certification#: 5244507-UC Expiration Date: 10/23/06 <br /> ALTERNATE <br /> Designated Operator's Name: Ed Steams Relation to UST Facility(Check One) <br /> Business Name(Ydifferentfrom above): CHAMPIONPRECISIONTESTMGMC E]-Owner C] Operator, E] Employee <br /> Designated Operator's Phone#: 916-927-1557 0 Service Technician m Third-Party <br /> International Code Council Certification#: 5450492-UC Expiration Date: 12/18/06 <br /> 1 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 /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Pnnt): <br /> SIGNATURE OF TANK OWNER-- <br /> DATE: OWNEWS PHONE#: <br /> ' <br /> Page l of November 2004 <br />