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UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQ T MENTS _ <br /> For use by Unidoes Member Agencies or where approved by your Local Jurisdic�kac g �d E <br /> Authority Cited: Title 23, Div. 3, CIL 16 California Code of Regulations(CCR 1 Y <br /> FACILITY NAME FACILITY PHONE <br /> Tower Mart# 886 (209) 823-2057 <br /> FACILITY SITE ADDRESSCITY A <br /> 1434 W. Yosemite Ave. Manteca, Ca 95337 HEALTH nE4R7nAENT <br /> REASON FOR SUBMIT iNG THIS FORM(Cheek One): Change of Designated Operator Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: Anthony (Paul) Chevalier RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(lfdlfferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (916)285-7402 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252195-UC EXPIRATIONDATE: 1/17/2014 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(O liana/) <br /> DESIGNATED OPERATOR NAME: Philip Crippen RELATIONTO UST FACILITY(Check One) <br /> BUSINESS NAME(If&fferentfrom above): ❑ Owner ❑ Operator 0 Employee <br /> DESIGNATED OPERATOR PRONE: (530)222-2348 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CF..RTIFICAT1ONNO.: 8020725-UC EXPIRATIONDATF: 11/12/2014 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdonat) <br /> DESIGNATED OPERATOR NAME: Thomas MCCalister RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME Qfdirferentfrom above): ❑ Owner ❑ Operator ® Employee <br /> DESIGNATED OPERATOR PHONE: (916) 847-2065 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 814355755-UC EXPIRATIONDATE: 11/2/2014 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(1fdierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br /> Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations,Title 23,Section 2715(c) through (f). Furthermore,I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANKOWNERNAME: NlckBattaglla <br /> TANKOWNERTITLE: General Mana er OWNER PHONE: 916 285-7402 <br /> TANK OWNER SIGNATURE: DATE: January 1, 2013 <br /> INSAUCTIONS <br /> 1. Report the namc(s) of the Designated UST Operator(s)as registered with the International Code Council (ICC). ICC certification <br /> information is available on-line at:www.iccsafe.org/e/certsearcb.html.Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and <br /> contact information are listed on-line at: www.unidoes.org/members/whoregiiiateswhat.htmi. Contact information for other <br /> local agencies within California is available at: www.swrcb.ca.gov/cwphome/ust/contacts/does/local_agency_Iist.xls. <br /> 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. <br /> UN-062-1/I wwwmaidomorg 09/22/05 <br />