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W3/04/2008 17 : 22 FAX 17074488182 TANK-TEK 1&002/003 UNDERGROUND STORAGE TANK SYSTEM 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 CaGfcrnia Code of Regulations (CCR) FACILITY NAME FACILITY PHONE Valero ) FACILITY SITE ADDRESS %6offill, CITY 2420 Grantline Rd Tracy REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator El Update Of l5eCanification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DES IGNATED OPERATOR NAME; Louis-Philippe Rooms LATION TO UST FACILITY(Check One) BUSINESS NAME Wdifererufrem aboWT Tank-Tek Environmental Corp. ❑ owner ❑ operator ❑ Employee DESIGNATED OPERATOR PHONE: (707) 446-6151 ext. ® Service Technician ❑ Third-Party INTERNATIONAL.CODE COUNCIL CERTIFICATION NO.: 5248336-UC EYPIRATION DATE: 12/16/2008 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY (O Nona! DESIGNATED OPERATOR NAME: Robert (Rob) Neimeyer RELATIONTO UST FACILITY(Check One) BUSINESS NAME(lfdLfferanlfrom above): Tank-Tek Environmental C rp. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (707) 446-6151 ex . ® Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 624$0674EXPIRATION DATE: 12/28/2008 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THT ACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifddferenrfram above): ❑ Owner ❑ Opwator ❑ Employee DESIGNATED OPERATOR PHONE: ( ext. ❑ Service Tcchnician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTITICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR OR THIS FACILITY(Opdon4t) DESIGNATED OPERATOR NAME RELATION TO UST FACILITY(Check One) BUSINESS NAME(dfdigerenf¢oto above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ext ❑ Service Tcchnician ❑ Third-Parry INTCRNATIONAL CODE COUNCIL CERTIFICATION O.; EXPIRATION DATE: I certify that, for the facility indicated the top of this page, the individual(s) listed above will serve as Designated UST Operator(s), The individual(s) will con uct and document monthly facility inspections and annual facility employee training in accordance with California Code of egulations, Title 23, Section 2715(c)through (f). Furthermore, I understand and am in compliance with the requirements tatutes, regulations,and local ordinances) applicable to underground storage tanks, TANK OWNER NAME: TANK OWNER TITLE: OWNER PHONE: TANK OWNER,SIGNATURE: L— DATE: ' // '- C- 7 INSTRUCTIONS 1. Report the name(s) of th Designated UST Operator(s) as registered with the International Code Council (ICC), ICC certification information is available -line at, www.iccssife.org/e/certSearch,html- Search for"California UST System Operators." 2. Submit this completed orm to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information ar listed on-line at: www.unidoes.org/members/whoreguiateswhat.html. Contact information for other local agencies within alifornia is available at: www.swrcb.ca.gov/cwphome/ust/contacts/doesAocal_agency list,xls. 3. 23 CCR §2715(a)re ices that you notify the local agency of any changes to this information within 30 days of the date of change. LIN-062.1t1 www.unidocs,org 09/22/05