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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For ase by Unidocs MemberAgencies or where approved by your Local Jurisdiction Authority Cited.• 7lde 23,Div.3,Ch. 16CaleforniaCmk ofBegalatiom(CCR) FACILITY NAME FACILITY PHONE j-'*1ir'd �" ArxJ ( =tog) 98z 5oa5 FACILITY SITE ADDRESS C 140 /f0041— REASON FOR SUBMITFING THIS FORM(Checkoae): LjChaWufDmgnstcdOperator Update of ICC Certification Expiration Dates) PRIMARY DESIGNATED UST OPERATOR FOR TIAs FACUM DESIGNATED OPERATOR NAME: Alex Jabb ri RELATION TO UST FACILITY(CheatOW) BUSINESS NAME Wdffereafom abow): Norcal Petroleum Services, Inc ❑ Owoer ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925)389-1262 ext ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIPICATION NO.: 9243897UC EXPIRATION DATE' 10162014 ALTERNATE I DESIGNATED UST OPERATOR FOR TFUS FACILYfS DEMONATEDOPERATORNAME AmirJabbelli REL TMTOUSTFACILM(ChVa On¢j BUSINESS NAME(Ydgfarerdfrwnabove): NOreal Petroleum Servk S, IRC ❑ Oamcr ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (9255)683-8879 ext ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: - '— 16 314) ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACII W(Ogeiarraq DESIGNATED OPERATOR NAME: .1 1RELATION TO UST FACILITY(Char*OM) BUSINESS NAME(Ifdj#kwrtfiom above): XZ ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR TIIIS FACHdTY(oyrierm9 DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Chao*Oay BUSINESS NAME({fdfJ'eeesfi above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ T bird•Pary INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: I certlry that, for the facility ladieatd at the top of this Page, the huWdaal(r) Rated above wRI carve as Designated UST Operator(a). The indivistaai(s)will ended and decmeat moetUy feeft h0pcetloro ami anneal fedWY C84ADlee traiafm` In accordance with California Code of Regaiatioes,Title A Section 2715(c)dweagh M Furthermore,I wederataed aced am in eompdiance with the requlreenenta(alatates,re9g�ahmosy and keg,ordbOACM)applicable to eaderareaed storage tads, TANK OWNER NAME: 9niaz ku--i I�ITY1rIY�� /r� I TANK OWNER TITLE: W`I✓P/ � OWNERPHONE: TANK OWNER SIGNATURE: _ DATE: �i ori- 13 INSTRUCTIONS L 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.iccszf*.ar g1elcerbewch,html. Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's UST& Unidocs member agency jurisdictions and contact information aro listed ore-hae at: wwwJM&CLOWMkMbershrhoreggatawhaLbtmI Contact infemation for Other local agencies within California is available at:www.swrcbx&rwic rpbomo*wtfcont=Wdocsllaeai_agaucy Ustab. 3. 23 CCR§2715(a)regairec that you notify the local agency of any changes to this information within 30 days of the date of change. Z a6ed %ed dH WVYO:I ME £0 fib'