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0 0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited- Title 23,Div.3, Ch. 16 California Code OfRegulations(CCR) <br /> FACIIdTY PHONE <br /> EFACILM <br /> Gas and Liquor <br /> clrY <br /> DRESS :d Manteca, CA <br /> osemite AveC e of Designated Operator ®Updateof ICC Certification Expiration Dates) <br /> MITTING THIS FORM(Check One): ❑ I�8 <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY RELATION To UST FACHITY(Check One) <br /> DESIGNATED OPERATOR NAME Alex JaMan <br /> ❑ Owner ❑ operator ❑ Employee <br /> BUSINESS NAME(IlfiJferemfromabwe): Norcai Petroleum Services, Inc ❑ Service Technician ® Third-Party <br /> DESIGNATED OPERATOR PHONE: (925)389-1262 ext <br /> INTERNATIONAL CODE COUNCII.CERTIFICATION NO.: <br /> 5297U EXPPIRATIONDATE: 10/6/2014 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACELITY(OptuxtO <br /> RELATION TO UST FACILITY(Check One) <br /> VDESIGNATED <br /> ATOR NAME: Amir Jabban <br /> ❑ Over ❑ Operator ❑ Employee <br /> �lle�at' a ) Norval Petroleum Services, Inc ❑ Service Technic an ® Third-Party <br /> ATORPHONE: (9Z5)6$3-$$79 extODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 1/312013 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Oplionat) REI.ATIONTOUST FACILITY(Check One) <br /> DESIGNATED OPERATOR NAME: <br /> BUSINESS NAME(If different from above): <br /> ❑ owner El Operates El Employee <br /> ❑ Service Technician ❑ Third-Party <br /> DESIGNATED OPERATOR PHONE ( ext. <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACRM(Oplwno RELATION TO UST FACILITY(Check One) <br /> DESIGNATED OPERATOR NAME: <br /> BUSINESS NAME(Ifd�JfereN from above): ❑ Owner El operator 11 Employee <br /> ❑ Service Technician ❑ Third-Party <br /> DESIGNATED OPERATOR PHONE: ( ext. <br /> IN'CERNATIONAL 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 /> TANK OWNER NAME: <br /> TANK OWNER TITLE: OWNER PHONE: <br /> TANK OWNER SIGNATURE: DATE: <br /> INSTRUCTIONS <br /> 1. Report the name(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 orgle%rtsearch.btml. 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 infomration are listed on-time at www.unidocaorg/membetslwhoregulateswhatbtmL Contact information for other <br /> local agencies within California is available at:www.swrcb ca goviewphomelastkontacts/docagoca1 agency_listzis. <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 rrww.®ido®.org <br /> 09122tos <br />