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Jun 24 05 04: 40p Rffnrda-Test (209) 794-0112 p. 3 <br /> Owner Statements of Designated Underground Storage Tank(UST)Operator <br /> X: <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility lO w: <br /> Facility Address: ACl�t�c. Reason for Submitting this Form(Check one) <br /> f t M Change of Designated operator <br /> Facility Phone C3Update Cerbfrcate Expiration Date <br /> Designated UST Operator(s)for this Facititsr <br /> PRIMARY <br /> Designated Operator's Name:JANINE KIRBY Retation to UST Facility(Cheer one) <br /> Business Name(if different from above).USTanx 0 Owner O Employee 0 Service Technician <br /> Designated Operator's Phone 0:(530)268-3949 0 Operator ■Third Party <br /> International Code Council Certification#:5244224-UC Expiration oate:10102/2006 <br /> ALTERNATE 7(Optional) <br /> Designated OpemWs Name:RANDALL KIRBY Relation to UST Facility(Check one) <br /> Business Name(N different*nm above} USTa nX Cl Owner 0 Employee 0 Service Technician <br /> Designated operator's Phone#:(530)268.3949 0 Operator M Third Party <br /> Intemitional Code Council CerVication#:52505664JC Expiration Date:1212812006 <br /> ALTERNATE 2(Opf a4 <br /> Designated Operator's Name:TERESA K[RBY Relation to UST Farr(Check ans) <br /> Business Name(if liferent tract above).USTanx C3 Owner 0 Employee 0 Service Technician <br /> Designated Operators Phone#.!"(530)268.3949 0 Operator ■Third Party <br /> International Coda Council Certification 0:5244507-UC Expiration Date:10!2312006 <br /> ALTERNATE 3(Optional) <br /> Designated Operator's Name: 1LY LE Relation to UST Faclity,(Check one) <br /> Business Name(S different fron abavex a Owner Cl Employee a Service Technician <br /> Designated Operator's Phone#. 269 -794- 016M C1 Operator 0 Third Party <br /> International Code Council Certification#: Y!qExpiration Date: )p IQ <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br /> wtTHIN 30 DAYS OF THE CHANGE. <br /> o�rtlflrtfrrR•f6ritllrs%VVIyIrdkaddst•thatop oftMspegs,thekovidwl(a)Iiiled'abOojvA <br /> ag�vtti as 0e'ilpr,tgcl uz+f OE>ara*sa►{s},The tndlu(%lsi(s)"4 Wn6act and dMoulift Monttttyr ' 11 <br /> iaa7ltt►Ntapectiorta Arad annaral hd6ty smptoyvp.bWmning.in eiWah rt m rift Callfamin Coda of <br /> . i • Regutegoetr,tfilazl,sedion27ts_(e�.-til• .• . <br /> �,.: .' artAfitirtnors,l unit r t n4.snd aro lit campjN mtas with no Mqutnara t(WNUfts, . <br /> r"Wadim.And fecal ardloonam)a"ilbatthis tfc tu+atrgrouir#s•tora8ott+nks.' <br /> NAME&TANK 0M 8t • . <br /> OR OWU Ms AlVlr(Ftesso P jrtt):_ +°+rn eon Nose UL <br /> GNATURE OF TANft wg <br /> Si1 <br /> QMMEROR dWNER'0)CGL'NT: <br /> dwte:_/?N�/_o 5' alrs� Nes: Lo/M:3i�S <br /> - <br />