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2815790 . 0 :01 P.M. 12-15-2011 2/2 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQ �+ For use by Unidocs Member Agencies or where approved by your Local JurisdictionTErt �F D Authority Cited: Title 13,Div, 3, Ch. 16 California Code of Regulations(CCR) a� FACILITY NAME FACILITY PHONE Ryder Truck Rental #1071 (209)943-3213 FACILITY SITE ADDRESS CITYPERMmj 141 A U16 LTH 3633 Duck Creek Drive Stockton y1cE Change of Designated Operator Update of ICC Certification Expiration Date(s) REASON FOR SUBMITTING THIS FOiW(Check One). PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Elmer Mortera RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdttferentfrom above): Balch Petroleum ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)942-8686 ext ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 6248052-UC EXPIRATION DATE: 5/3/2013 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY O nal DESIGNATED OPERATOR NAME: Ryan Upert RELATION TO UST FACILITY(Check One) BUSINESS NAME(1dii erentfrom above): Balch Petroleum ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5295268-UC EXPMATIONDATE: 10/22/2012 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Rolando Urbma RELATION TO UST FACILITY(Check One) BUSINESS NAME(lfdijjemntfromabove): Balch Petroleum ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)942-8686 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8069631-UC EXPIRATIONDATE: 10/29/2012 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACHM(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdigerentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party 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 (t). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK owNERNAmE: Amy White (281)647-8900 TANK OWNER TITLE: Senior Comlianize Manager, OWNER PHONE: X208 TANK OWNER SIGNA DATE: December 14, 2011 INSTRUCTIONS I. 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.ieesafe.org/e/certsearch.html.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Undoes member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.btml. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contactddGcs/lociL_agency_Hst.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/I www.uaidocsorg 09/22/05