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UNDEPROUND STORAGE TANK S it STEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by Your Local Jurisdiction Authority Cited Title 23,Div. 3, Ch. 16 California Code of Regulations(CCR) FACILITY NAME FACH-M PHONE Love's Country Store#223 (209)599-0740 FACILITY SITE ADDRESS CITY 1553 Colony Rd. Ripon REASON FOR SUBMITTING THIS FORM(Check one)_ ❑Change of Designated Operator N Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACE ITY DESIGNATED OPERATOR NAME: Zane A_ Nimmo, RELATION TO UST FACILITY(Check One) BUSINESS NAME(If&fferent frons above)_ Afforda -Test ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (209) 744-0112 12 ext- ❑ ice Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO- 5263322 - UC EXPIRATION DATE_ 3/27/2010 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACMITY(Optional) DESIGNATED OPERATOR NAME: David A. Winkler RELATION TO UST FACILITY(Check One) BUSINESS NAME(lfdO&rentfrom above): Afforda -Test ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (209)744-0112 ext- ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5263373- UC EXPIRATION DATE: 3/14/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdono DESIGNATED OPERATOR NAME: C. Kevin Nickell RELATION TO UST FACILITY(Check One) BUSINESS NAME(YOfferenifrom above): Loves Country Stores ❑ owner ❑ operator ® Employee DESIGNATED OPERATOR PHONE: (405)380-5796 ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO: 8014175- UC EXPIRATION DATE: 7/3112010 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACELITY(Opt mwo DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(IfaVf rentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext- ❑ Service Technician ❑ Thrid-Patty INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations,Title 23,Section 2715(c)through(f). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: C. Kevin Nickell for Love's Country Stores of California TANK OWNER TITLE: Environmental Compliarlpe,A,4alysl ouNERPHoNE: (405)302-6640 TANK OWNER SIGNATURE: DATE: July 6, 2009 INSTRU NS 1. Report the names)of the Designated UST Operator(s)as registered with the International Code Council(ICC). ICC certification information is available on-line at:www.icesafe.org/elcertwarch.htad. Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/memberstwhoregulateswhathtmi- Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ost/coutacts/docs/local agency_list.als. 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062-In www.unidocs.org 09/22/05