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r' <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: ( `J -76 Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> e <br /> n � <br /> Change of Designated Operator <br /> Facility Phone#: E ❑ Update Certificate Expiration Date <br /> Designated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Chuck Hill Relation to UST Facility(Check One) <br /> Business Name(If dierent from above):CHAMPION PRECISION TESTING INC ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-927-1557 R Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5250259-UC Expiration Date: 12/17/06 <br /> ALTERNATE 1 O donal <br /> Designated Operator's Name: Ed Stearns 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 j <br /> International Code Council Certification#: 5450492-UC Expiration Date: 12/128/06 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:ALVIN MILBURN Relation to UST Facility(Check One) <br /> Business Name(If dierent from abave): CHAMPION PRECISION TESTING INC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-927-1557 R Service Technician ❑ 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) -(fl. <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): ,-n/7 c'l� �� /�� h/ n <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 6 2--/g-�, :(' OWNER'S PHONE#: 2 ) L-i 1 6 <br /> C , <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:N,,—Nvw.waterboards.caaoN-/ust/contacts/ciipa ages html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />