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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#876 (209) 727-5442 FACILITY SITE ADDRESS CITY 14000 East Hwy 88 Lockforde, CA 95237 REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY RELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: Anthony (Paul) Chevalier BUSINESS NAME(Ifdiffiuent from 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: 2I28/201 O ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY O liana! RELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: George Ayers BUSINESSNAME(Ifdi)reremfromabove): ❑ Owner EJ Operator ® Employee ❑ Service Technician ❑ Third-Party DESIGNATED OPERATOR PHONE: (916)798-0499 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: $004556 EXPIRATION DATE: 1/$/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DRELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: Roy George BUSINESS NAME(/fderemfrom above): ❑ Owner ❑ Operator ® Employee 916 316-5479 ext. ❑ Service Technician ❑ Third-Party DESIGNATED OPERATOR PHONE: ( ) INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: $004562-UC EXPIRATION DATE: 2/12/2010 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: KU rt Ivy RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdi�eren(from above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (707) 849-1724 ext. El Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8001563-UC EXPIRATION DATE: 1/22/2010 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 (1). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANKOWNERNAME: Nick Batta Iia TANK OWNER TITLE: Genera ana er OWNER PHONE: 916 285-7402 TANK OWNER SIGNATURE: DATE: October 20, 2008 INSTR TIONS 1. Report the name(s)of the Designated UST Operator(s) as registered with the International Cade 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.btml. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_IiSt.XIS. 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 www.unidocs.org 09/22/05