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(P I l <br /> All 3 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) <br /> and Understanding of and Compliance with UST Requirement PERf�IIR��iB�MLc� HEALTH <br /> NTI <br /> Facility Name: -f(Ai,A�S Facility ID#: <br /> Facility Address: 11 Reason for Submitting this Form (Check one) <br /> l�� N ox-w\��r n ��,LOA,i,CA listH� M Change of Designated Operator <br /> Facility Phone#: _ q_ 11Ck& ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: RANDALL KIRBY Relation to UST Facility(Check one) <br /> Business Name(If different from above): USTanx ❑ Owner ❑ Employee ❑ Service Technician <br /> Designated Operator's Phone#:(530)268-3949 ❑ Operator ■ Third Party <br /> International Code Council Certification#: 5250566-UC Expiration Date: 06/30/2012 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: NIKKI KIRBY Relation to UST Facility(Check one) <br /> Business Name(If different from above): USTanx ❑ Owner ❑ Employee ❑ Service Technician <br /> Designated Operator's Phone#:(530)268-3949 ❑ Operator ■ Third Party <br /> International Code Council Certification#:8018545-UC Expiration Date: 09/23/2010 <br /> ALTERNATE 2(Optional) <br /> Designated Operator's Name:JASON KIRBY Relation to UST Facility(Check one) <br /> Business Name(If different from above): USTanx ❑ Owner ❑ Employee ❑ Service Technician <br /> Designated Operator's Phone#:(530)268-3949 ❑ Operator ■ Third Party <br /> International Code Council Certification#:5270158-UC Expiration Date: 09/12/2011 <br /> ALTERNATE 3(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check one) <br /> Business Name(If different from above): ❑ Owner ❑ Employee ❑ Service Technician <br /> Designated Operator's Phone#: ❑ Operator ■ Third Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br /> WITHIN 30 DAYS OF THE CHANGE. <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)-(f). <br /> Furthermore, I understand and am in compliance with the requirements(statutes, <br /> reguations, and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER ; <br /> OR OWNER'S AGENT(Please Print) : a Loo <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: 1 21 <br /> DATE: �'�1'dl�ll> O NER'S PHONE# : �61e 5'�1l�'?s�S <br />