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02/2712009 16:32 FAX 17074466192 TANK-TEK [003/004 <br />�riJNDERGRO SSi�® GAET iANK t' c SYSTEM rn <br />MWi <br />— A conr.rAx wrT uS U TS <br />Fnr use by Unddcxx r12'�r►rber A�ruies or where approved !ay yrnrr LncvlJurrsdlGiart <br />1 r 7 ble .23, Div. 3, CIA 16 Cal horn/a Coda of lUgulatior s (CCM <br />PACIUTYMANOM <br />N COUNTY <br />.ha <br />1469 E. HAMMER LANE <br />DBSIONNFBOOPPATORNAM71- Virginia Fulg <br />BUS1MS$ NAME (ry'4*re uh— mhm)- Tank -Tek <br />— II II <br />_ A • <br />• <br />Updatc of ICC Ceftidication T;xpimion s) <br />RM ATION 710 UST FACII.rry (Chea O)w) <br />Cl Owner ❑ Operator ❑ Employee <br />❑ Service Tccludclan 0 Third -Party <br />Tr4TIRRNATIONAL CODE• • • 57L44LC -111W IaWTAati6►LYIYh:►�c,� <br />nPSrQPi OPERATOR NAW: Michael (Mike) Lawrence <br />i3u9NESS NAME (j 'd( m1foro a abov0-. Tank-T®k Environmental Corp. - <br />.. •RPROMR: (707)"-6 <br />TO UST FACILITY (Check Oxy! <br />❑ Owner ❑ Operator ❑ Employed <br />® Service Technician ❑ Thlyd-Party <br />OUSIGNATED OPERATOR NAME: <br />1 . <br />RELATION TO UST FACILITY (awat 0>taJ <br />❑ owner ❑ opemetor ❑ Employee <br />❑ ice Technician ❑ Third -Party <br />13USMSS NAME (ItOffam firm <br />RI) <br />DBSIONA OPEIWOfR PHONE: �, <br />INTERNATIONAL COD'B COUNCII. CF.R 11F1CATION NO.: <br />E7 MA71ON DATE: <br />T97-1 wr ■ .1 it 1/'t <br />DE-SiONATfiim CIPERA7QR NAME: <br />"I.ATION TO UST FACILITY (Cfaelek O#W <br />❑ ow= ❑ Oparaior ❑ Employee <br />❑ Service 'Technician ❑ Third -I aAY <br />fouS1NP44NANM (l!d(f mnelrom abow); <br />DESIGNATED OPERATOR PHONE; <br />INTERNA IJONAL CODE COUNCIL CERTIFICA 1014 NO.: <br />EXPIRATION DATE; <br />I certify that, for the faeility indicated at the top of this page, the individual(s) listed above will serve as Designated LIST <br />Operstor(a). The Indlviduai(s) will conduct and document monthly facility inspections and annual Facility employe$ tralnlag <br />In accordance with Califomis Code of Regulations, Title 23, Section 27)5(c) through Q). Furthermore, l understand and am <br />In compliance with the requiremeats (statuteal regulaitjoaa, and local ordlaanees) applicable to underground storage tanto. <br />TANK OWNER NAME: V hU - <br />TANK OWNER TITLE: <br />FWNZN�e� <br />1. Report the name(s) of the Denignated UST O r(s) as msiftermd with the International Code Council (ICC). ICC cord6cation <br />infornation is available on-line at: www.kxsa&orWe/ce arch.html. Search for—California, US'r system tors; <br />2. Submit this completed farm to the local agency did regulates this facility's USx9. Unidocn member agency,urisdWcois and <br />contact information aro listed oft -line at: www.un*adoes.org/mombar&twboragulmhwwbathtml, Contact information for other <br />local agencies within California is available at: www.swreb.ca.gov/cwlll eme/usttcontseb/d ocal agencYjfst.xls. <br />3. 23 CCR §2715(x) requhts that you notify the local agency of any changas to this information within So days of'the dam of change. <br />UN -062 - ]A WWW.u0id0=W9 094=5 <br />