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0 0 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Undoes 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 # 876 (209)824-1375 FACILITY SITE ADDRESS CITY 14000 E. Highway 88 Lockeford REASON FOR SUBMITTING Ili IS FORM(Check One): Change of Designated Operator N Update of ICC Certification Expiration Dalc(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Anthony (Paul) Chevalier RELATION TO UST FACILITY(Check One) BUSINESS NAME(Y'dif/eremfrom above): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PI LONE: (916) 285-7402 ext. 181 ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252195-UC EXPIRATION DATE: 10/16/2016 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY O tiona! DESIGNATED OPERATOR.NAME: Ryan Monte RELATION TO UST FACILITY(Check One) BUSINESS NAME(If dii erentfram above): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PHONE: (530) 518-1177 ext. ❑ Service'rechnician N Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8182860-UC EXPIRATION DATE: 11/10/2016 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) _ DESIGNATED OPERATOR NAME: Denise Esse RELATIONTOUSTFAC1LlT'Y(Check(ane) 131JSINESS NAME(lfdlfjerentfromabove): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PHONE: (916) 849-1724 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8093066-UC EXPIRATION DATE: 7/26/2015 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Nu-Gina Rogers RELATIONT'O UST FACILITY(Check One) BI ISINF.SS NAME(/fd&.renrfrom above): ❑ Owner ❑ Operator N Employee DESIGNATED OPERATOR PHONE: (916)425-9429 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL.CERTIFICATION NO.: 8249377-UC F.XPIRATIONDATE: 10/3/2016 1 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. TANK OWNERNAME: Romy QUIFOZ TANK OWNER TITLE: Retail Operations, ager OWNER PHONE: (707) 853-6653 TANK OWNER SIGNATURE: DATE: January 1; 2015 -_7 INSTRUCTIONS 1. Report the names)of the Designated UST Operator(s) as registered with the International Code Council(ICC). ICC certification information is available on-line at:www.icesafe.org/e/certsearch.litmi.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/whoregulateswbat.htmi. Contact information for other local agencies within California is available at: www.swreb.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-.VI www.unidocs.org 09/22/05