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03/12/2010 13: 14 FAX 170744661 2 TANK-TEK 003/004 <br /> P, <br /> UNDERGROUNDSTORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR <br /> UNDERSTANDING OF AND COMPLIANCE UST REQUMEMENTSi <br /> „For use by Unidocs Member Agencina or where approved by your Local Jurisdiction <br /> Authority Cited. Tide 23,Diu. 3,Ch 16 California Co&of ations(CCI) <br /> FACILITY NAME FACILrrY PWNB <br /> CLLC#2705"7 209-478-1522 <br /> FAaLrry srra ADDRSSS CITY <br /> 1"9 E. HAMMER LANE STCTO <br /> REASON FOR 5 G THIS FORM(Check Orae)' Chomp of Update of 1CC on�° S) <br /> p X DESIGNA UST OPERATOR FOR THIS FACILITY <br /> 6W—IGNATEDOPE ATOR NAME: icha Tho s TION To UST FACILITY(cock Oen) <br /> SUSINFSS NAME(If rwwfr'om above): Tank Tek Environmental Corp. 0owner ❑ Opp r [:] Employce <br /> DESIGNATED OPERATOR PHONE. (707) 6.6151 ext ❑ Service Tedanician 9 Tl&d-Petty <br /> A=NAL CODE coUNcn.CERToCATION No.: 5254736-UC TION DATE: 1/2012011 <br /> ALT ATE 1 DESIGNATED UST OF TOR FOR THIS FACiLATY(OpdonqQ <br /> DESICINATED OPERATOR NRZATION TO UST FACILITY(Chet Ore) <br /> BUSOMS NANE(Il 4ftmmfiran®bona): Owner 13 OPWLWr ❑ Employce <br /> DESIONATM OPMIATOR PHONE: S"M Technician ❑ Third-P <br /> aity <br /> ATIONAL CODE COUNCIL CERTIFICATION NOEXPIRATION DATE: <br /> ALTMATR 2 DLSIGNATFM UST OPERATOR FOR THIS,FACILITY(optic") <br /> DWGNA.TM OPERATOR NAME: TION TO UST FACILITY(Cluck one) <br /> BUSINESS NAME QrdWfiM rfiV0 abaw): ❑ ovmer opemr ❑ Employcc <br /> DESIGNATED OPERATOR PHONE Service Technician ❑ -Pavy <br /> INTsRNATIONAL CODE COUNCIL CERTMCATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR IRM FACILITY(optic ) <br /> DESIG NATM OPERATOR NAME: RELA=N TO UST FACIIATY(Check Ore) <br /> BUSDMS NAM(TfdiPmwfivm above): Owner ❑ opftlw ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ❑ Service TwImician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCZ CERTWICATON NO.. EXPIRATION DATE: <br /> I @ertiry that, for the facility Indicated at the top of this pap, the iudividual(s) listed above will sme as DesipatedUST <br /> Operator(s). The individuals)wiU conduct and document monthly facWty inspections and annual facllitry employee training <br /> in accordance with California Code of Regulations,Title A Section 2715(c)throe (Q. Furthermore,I understand and a <br /> in compliance with the requirments(statutes,regulatlans,and IoW ordinances)applicable to underground storage tankL <br /> TANKOWNMNAME., CRLLC / Designee: Armen Mkrtychian <br /> T O . Compliance Manager O RPHONE: 925 884-0800 <br /> TANK OWNER SIGNATURE:. DATE: c <br /> INSIR—fiCTIONS <br /> 1. Rpport the s)of the Designated UST s)w registered with the Internationd Code Council(ICC). ICC certificaton <br /> information is available on-line at: fe.orWeJecrtsearcb.btuii.Search for"California UST System Operators." <br /> 2. Submit this completed form to ft local agency that regulate& this facility's USTs. Unidocs manber agency jurisdictions and <br /> coaact information are Usted on-line at: www.unidoc&org/members/whorqaliteswkat.htmL Con 'on for other <br /> local agendes wiCaliftmdais available at b.mgov/ bo sV to d _ eney_list. . <br /> 3. 23 CCR§2715(1)requires diaz you notify the local agency ofany changes to this Information widAn 30 days ofthe daft of change. <br /> UN -td 09/22/05 <br />