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• ' Jun 28 05 12:02p Rfforda-Test (2091 794-0112 <br />-Iwo <br />i <br />i... Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Facility t0 # <br />FadrP Address: 34-N ( amener La-ne,. Reason for SubmAting ft Form (Check one) <br />S 6C. • orange of Designated Operator <br />Fac iRy Phone # : C? 0 Update Certirxats Expiration Date <br />Designated UST Operators) fqr ththis EgellitX <br />PRIMARY <br />Designated OperatoeS Name: JANINE KIRBY <br />Relation to UST Facility (Check are) <br />0 Owner 0 Employee 0 Service Technician <br />® Operator ■ Thad Party <br />Wssiness Name (if different from etxme): USTanX <br />Designated Operators Phone # : (530) 268.3949 <br />international Cade Council Certification #: 5244224 -UC <br />9*ration Data: 10102/2006 <br />ALTERNATE I(QX V4 <br />Designated Operators Name: RANDALL KIRBY <br />Relation to UST Facility (Check om) <br />0 Owner O Employee ❑ Service Technician <br />0 Operator ■ Third Party <br />Business Name (if dKerent from above}: USTanX <br />Designated Operator's Phone #: (530) 26&3949 <br />International Code Corwin Certir=ation #: 5250566 -UC <br />P91ration Date: 12a=006 <br />LT%E4:il"�i*X&M7;f?)> <br />Designated Operator's Name: TERESA KIRBY <br />Relation to UST Facility (Check one) <br />0 Owner 0 Employee 0 Service Technician <br />13 Operator IN Third Pasty <br />Business Name (If di ferent tram above}: USTanX <br />Designated Operators Phone #: (530) 268-3949 <br />lntemational Code Council cerlification 0: 5244W -UC <br />Expiration Date: 1012312006 <br />,L.TERNATE 3 (Opfi'oniaf) <br />esignated Operator's Name:�Y LE 1 Relation to UST Facitity (Check case)) <br />usiness Name (M different from above} 0 Owner 0 Employee to Service Technician <br />Designated Operator's Phone # : 2209 y _ O ®b Z 0 Operator 0 Third Party <br />wternational Code Council ay!qExpiratb n Dete: fm� <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br />WITHIN 30 DAYS OF THE CHANGE. <br />! car" #ML for We facility► hKikawd at tha top of ttds Page bre s) &shod above wit <br />serve as Designated UST s). The kgtividuagswill Conduct and domment axxgNy <br />Old taOVY Cfflpbyce WasurM. in accordance wi0 CaA(MM Code of <br />R ns. We 23, Section 2715 (C) <br />F saner*, I undanoand and arse in sora Wilth the requirements <br />oeguations. and local ordinances) appillcaMe to underground storago tanks:. <br />NAME OF TANK ownEIR 0q <br />ORO (PleMe Print) : 04LA Frti 4 Wal - <br />SIGNIATURE OF TANK 4C: <br />OWNIER ORS AG;W- <br />QA7 E- ®jam OWNER'S ONEJe7j�(, , 4o.OGg <br />p.2 <br />