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Jun 28 10 0&43a B G Group 70460441 P.3 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR 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 Fast Lane (209)234-4341 FACILITY SITE ADDRLSS CITY 116 E. Roth Rd. Lathrop REASON FOR SUBMITTING THIS FORM(neck One): Change of Dcsignated Operator Update of1CC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY RELATION TO UST FACILITY(neck One) DESIGNATED OPERATOR NAME: Brian UIlnahay BUSINESS NAME(/fdi(rererdfMmabov e): EPIC Compliance Systems ❑ Offer' ❑ Operator ❑ Employee 888 700-EPIC ext ❑ Sen ice Technician ® Third-Party DESIGNATED OPERATOR PHONE: ( ) INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: $021436 - UC EXPIRATIONDATE: 12I6I2010 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILTFY(O tional) RELATION TO UST FACILITY(Check One) DESIGNATHDOPERATORNAME: AI Milburn BUSINESS NAVE(If dierentfrom above): EPIC Compliance Systems ❑ Owner ❑ Operator ❑ Employee Service Technician ® Third-Party DESIGNATED OPERATOR PHONE: (888) 700-EPIC ext. ❑ INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 0878948- UC EYPIRATIONDATE: 12/617010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(OpAunalJ DESIGNATED OPERATOR NAME: RELATION TO UST FAC ILR'Y(Check Oae) BUSINESS NAME(IfdifTerentfram above): ❑ Owner ❑ Operator E) Employee ❑ Service Technician ® Third-Party DESIGNATEDOPFRATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCCERTIFICATION NO.: EXPIRATION DATE: IL ALTERNATE DESIGNATED UST OPERATOR FOR THIS FACILITY(Optionap DESIGNATID OPERATOR NAME: RELATION To UST FACILITY(Chuk One) iff BUSINESS NAME((fdereretfromabave): ❑ Owner ❑ Olxxator [ Employee ❑ ServiceTechme' ❑ Third-Party DESIGNATED OPERATOR PHONE ( ) ext. INTERNATIONAL CODE COUNCn.CERTIFICATION NO.: EXI'TRATTON 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. TANKOWNERNAME: C C��CvPSI 1�—C' TANK OWNER TITLE: P4Cr✓ O WNER PHONE: (70-1 6 TANK OWNER SIGNATURE: DATE: f_ DATE: INSTRUCTIONS 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 atwwwdecssfe.org/elcertsearch.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.unidoes.org/members/whoregulateswtiat.html. Contact information for other local agencies within California is available at:www.swrcb.ca.govfcwphome(usUcontacts/docsliocal_agency_liSLxls. 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 changc. 09/22AS UN-062-1/1 »'ww.unidocs.org