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UNDAROUND STORAGE TANK 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 FACILITY PHONE Tower Mart# 876iL- (209)727-5442 FACILITY SITE ADDRESS CITY 14000 East Hwy 88 Lockford,CA 95237 REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Lg Update of ICC Certification Expiration Dat s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Anthony (Paul) Chevalier RELATION TO UST FACILRY(Check One) BUSINESS NAME(Ifd jreremfrom above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (916)285-7402 ext. 104 ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252195-UC EXPIRATION DATE: 1/20/2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FAC II TTY O uonaJ DESIGNATED OPERATOR NAME: Ryall Monte RELATION TO UST FACILITY(Check One) BUSINESS NAME(If dierenrfrom above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (530) 518-1177 ext, ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8089338-UC EXPIRATION DATE: 11/19/2012 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Romy QUiroz RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdii eremfrom above): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PHONE: (707)853-6653 ext, ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5280209-UC EXPIRATION DATE: 1/4/2012 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfrom above): El owner [I operator El Employee El Service Technician E] Third-Party DESIGNATED OPERATOR PHONE: ( ) ext. 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. TANKOWNERNAME: NickBatta lla TANKOWNERTITLE: General Mafia erOWNER PHONE: 916 285-7402 TANK OWNER SIGNAT DATE: January 3 2011 INS UCTIONS 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.iccsafe.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. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_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 w .unidacs.org 09/22/05