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F <br /> s b <br /> a "Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Facility Address: Reason for Submitting this Form.(Check Orae) <br /> ■ Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> ALTERNATE 4( ' nal) <br /> Designated Operator's Name: Ronald Briddick Relation to UST Facility(Check One) <br /> Business Name(If different from above):CHAMPION PRECISION TESTING INC ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-927-1557 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5256869-UC Expiration Date:03/09/07 <br /> ALTERNATE 5 CQpdonaq <br /> Designated Operator's Name: Chuck Hill Relation to UST Facility(Check One) <br /> Business Name(Ifd fferent from above): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-927-1557 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5250259-UC Expiration Date: 12/17/06 <br /> ALTERNATE 6 ( nal) <br /> Designated is Name:Dan Boley Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Desi is Phone#: 916-927-1557 ❑ Service Technician N 'Third-Party <br /> International Code Council Certification#: 5250411-UC Expiration Date: 12/17/06 <br /> ALTERNATE 7 ( nal) <br /> Designated Operator's Name:ALVIN MILBURN Relation to UST Facility(Check One) <br /> Business Name(If different from above): CHAAfl'10N PRECISION TESTING INC. ❑_Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-927-1557 ❑ Service Technician ■I Third-Party <br /> International Code Council Certification#: 0878949-UC Expiration Date: 12/15/06 <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 /> 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 Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#• <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)$Y-JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: <br /> «iN-NN-.ti-aterboards.ca.Qov/ust/contacts/cupa agvs.htnih. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITIM 30 DAYS OF THE <br /> CHANGE. <br /> Page 2 of 2 November 2004 <br />