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UNDEOGROUND STORAGE TANK S*TEM RECEIVED OWNER STATEMENTS OF DESIGNATED UST OPERATOR 2011 UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIRE For use by Unidocs Member Agencies or where approved by your Local Jurisdiction ENVIRONMENTAL HEALTH Authority Cited.• Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) PERMIT/SERVICES FACILITY NAME FACILITY PHONE Tower Market# 876 (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 0 Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Anthony (Paul) Chevalier RELATION TO UST FACILITY(Check One) BUSINESS NAME(If differentfrom above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (916) 285-7402 ext. 104 ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252195-U(; EXPIRATION DATE: 01120/2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY O Ronal DESIGNATED OPERATOR NAME: ToryLora RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdieremfrom above): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PHONE: ( 916 ) 285-7402 ext. 107 ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: $054460-UC EXPIRATION DATE: 1/20/2012 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Roy George RELATION TO UST FACILITY(Check One) BUSINESS NAME(If dierem¢om above): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PHONE: (916) 316-5479 ext, ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8004562-UC EXPIRATIONDATE: 2/3/2012 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATEDOPERATORNAME: Christopher FOuntaine RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdigerentfrom above): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PHONE: (916)285-7402 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: $020700-U C EXPIRATION DATE: 1/2O/2012 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: Nick Battaglia TANKOWNERTITLE: General Man,,a er OWNER PHONE: 916 285-7402 TANK OWNER SIGNATURf. DATE: January 3, 2011 INS UCTIONS 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.iccsafe.org/e/certsearch.htmi.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/whoregulateswhatbtmi. Contact information for other local agencies within California is available at:www.swreb.ca.gov/cwphome/usVcontacts/does/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/t www.unidocs.org 09/22/05