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2815790664 RYDERSYSTEMS • 02:23:28 p.m. 11-11-2013 2/2 is UNDERGROUND STORAGE TANK SYSTEM RECEIVED OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMNaj9I'F2 2013 For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 13, Div. 3, Ch. 16 California Code of Regulations(CCR) ENVIRONMENTAL HEALTH FACILITY NAME FACILITY PHONE D Ryder Truck Rental 1071A (209) 943-3213 FACILITY SITE ADDRESS CITY NOV 12 2013 3633 Duck Creek Drive Stockton REASON FOR SUBMITTING THIS FORM(Check One) LJ Change of Designated Operator N Update of ICC Certificati TH PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY PERMIT/SERVICES DESIGNATED OPERATOR NAME: Elmer Mortera RELATION TO UST FACILITY(Check One) BUSINESS NAME(/fdifferentfrom above): Balch Petroleum ❑ Owner Cl Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 524N052-UC EXPIRATION DATE: 4/22/2015 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Ryan Lipert RELATION TO UST FACILITY(Check One) BUSINESS NAME(ydi,(ferentfrom above): Balch Petroleum ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5295268-UC EXPIRATION DATE: 10/17/2014 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Rolando Urbina RELATION TO UST FACILITY(Check One) BUSINESS NAME(/fdifferentfrom above): Balch Petroleum ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8009631-UC EXPIRATIONDATE: 10/24/2014 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Robert Henninger RELATION TO UST FACILITY(Check One) BUSINESS NAME(lfdfferentfrom above): Balch Petroleum ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)942-8686 exL ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252265_UC EXPIRATION DATE: 2/25/2014 I certify that, for the facility indicated at the top of this page, the individuals) listed above will serve as Designated UST Operstor(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: (Ary (�� TANK OWNER TITLE: I I �� ((Il 6l(i L V I OWNER PHONE: ' F- i C'L „ TANK OWNERSIGNATU� i t_- l ( DATE: INSTRUCTIONS 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council (ICC). ICC certification information is available on-line at:www.iccsare.org/e/certsearch.himi. 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/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/does/local_Rgency_list.xls. 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-062-1/1 www.aoidocs.org 09/22M5 Received Time Nov. 11. 2013 12 : 23PM No, 4493