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UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Undoes Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited: Title 23,Div. 3, Ch. 16 California Code of Regulations((.,CR) <br /> FACILITY NAME FACILITY PHONE "- <br /> Tower Mart# 876 (209) 727-5442 <br /> FACILITY SITE ADDRESS CITY <br /> 14000 E. Highway 88 Lockeford <br /> REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator ®Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: Anthony (Paul) Chevalier RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME Qfd{Qerenrfrom above): ❑ Owner ❑ Operator ® Employee <br /> DESIGNATED OPERATOR PHONE: (916)285-7402 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252195-UC EXPIRATION DATE: 10/16/2016 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(O tlonat <br /> DESIGNATED OPERATOR NAME: Ro171y QUIroz RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdii femntfrom above): <br /> ❑ Owner El Operator ® Employee <br /> DESIGNATED OPERATOR PHONE: (707) 853-6653 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL.CODE COUNCIL CERTIFICATION NO.: 5280209-UC EXPIRATIONDATT: 12/20/2015 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY­rat) <br /> DESIONATED OPERATOR NAME: ROy George RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdrenrjram above): Owner <br /> ❑ ❑ Operator ® Employee <br /> DESIGNATED OPERATOR PHONE: (916)316-5479 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: $004562-UC EXPIRATION'DATE <br /> 1/2016 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR TIAs FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: Christopher FOuntalne RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(tfd(fferewfimm above): ❑ Owner ❑ Operator ® Employee <br /> DESIGNATED OPERATOR PHONE: (916) 285-7402 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8020700-UC EXPIRATION DATE: 10/16/2016 <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br /> Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations, Title 23,Section 2715(c) through(f). Furthermore, I understand and am <br /> in compliance withthe requirements(statutes, regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNER NAME: ROmy Quiroz <br /> TANK OWNER TITLE: Re!nr <br /> Operations ag <br /> er OWNER PHONE: 707 853-6653 <br /> TANK OWNER SIGNATUREDATE: January1, 2015 <br /> TIONS <br /> . Report the name(s)of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification <br /> information is available on-line at: www.iccsafe.org/e/certsearch.htmi.Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's IJSTs. Unidoas member agency jurisdictions and <br /> contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.htmi. Contact information for other <br /> local agencies within California is available at:www.swreb.ca.gov/cwphome/ust/contacts/docs/local_agency_lisLxls. <br /> 3. 23 CCR§2715(x)requires that you notify the local agency of any changes to this information within 30 days of the date of change. <br /> UN-062-1/1 www.unidoee.org 09/22/05 <br />