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UNDER OUND STORAGE TANK SY M OWNER STATEMM"S OF DESIGNATED UST OVERATOR 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 Market# 886 (209) 239-1792 FACILITY SITE ADDRESS CITY 1434 W. Yosemite Ave. Manteca,Ca 95337 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 DESIGNATED OPERATOR NAME: Anthony (Paul) Chevalier RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdierentfrom 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: 1/17/2014 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY O tiond DESIGNATED OPERATOR NAME: Romy QUIroz RELATION TO UST FACILITY(Check One) BUSINESS NAW(Ifdierenifrom above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (707) 853-6653 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5280209-UC EXPIRATIONDATE: 1/26/2014 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Roy George RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdierenifrom above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (916) 316-5479 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8004562-UC EXPIRATIONDATE: 1/19/2014 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Christopher FOuntalne RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifleremfrom above): ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (916) 285-7402 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8020700-UC EXPIRATION DATE: 1/17/2014 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 (f). Furthermore, I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANKOWNERNAME: Nick Battaglia TANK OWNER TITLE: General Manager OWNER PHONE: 916 285-7402 TANK OWNER SIGNATURE: DATE: January 31, 2012 IN RUCTIONS 1. 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.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.unidocs.org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at: www.swrcb.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-062.1/1 www.unidocs.org 09/22/05