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kC �I�& UNDE.":GROUND STORAGE TANK < y�ta G STEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs MemberAgencies or where approved by your Local Jurisdiction Authority Cited Title 23,Div_3, Ch. 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Manteca Liquor-Food (209)239-4550 FACILITY SITE ADDRESS CITY 890 N Main St Manteca, CA REASON FOR SUBMITTING THIS FORM(Check One): ❑Change of Designated Operator 9 Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACHITY DESIGNATED OPERATORNAME: Alex Jabban RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifererafromabme): Norcal Petroleum Services, Inc ❑ owner ❑ operates 11 Employee DESIGNATED OPERATOR PHONE: (925)389-1262 ext ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243897UC EXPIRATION DATE: 10/6/2014 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY( DESIGNATED OPERATOR NAME: Amir Jabbari RELATION TO UST FACILITY(Check Om) BUSINESS NAME(Ifd�fferenrfrom above): NOrcal Petroleum Services, Inc ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925)683..8879 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 1/3/201#5' ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(OptiM4 DESIGNATED OPERATOR NAME: RELATTON TOUSTFAC IM(Check One) BUSINESS NAME(If dtfferenrfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO_: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(opdonay DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(If differentf om above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 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. TANK OWNER NAME: (f.�(/�rT�� /` S' SFJ d✓/�al l TANK OWNER TITLE: — OWNER PHONE: TANK OWNER SIGNATURE: DATE: I( — •,9 INSTRUCTIONS I. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council (ICC). ICC certification information is available on-lirw at:www.iccasfe.org/e%rtsearch html. Search for"Califomia 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.swreb-ca.gov/cwphometusVeontacWdocsfiocaLagency_fistxb. 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.mida mz 09/22/05