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May. 15. 2007 8: 01AM No, 0823 P. 3 UN IRGROUND STORAGE TANK0YSTE M OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS F'AC'ILITY NAME FACILITY PHONE ConocoPhillips Site # 2708671 (209)478-8959 FACILITY SITE ADDRESS CITY 8606 Thornton Rd,CA Stockton REASON POR 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: Sernu N. Habte RELATION TO UST FACILITY(Check One) BUSINESS NAME(If differenifrom above): ❑ Owrle< ® Operator ❑ Employee DESIGNATp_.D OPERATOR.PHONE: (010) 782-1172 ext_ ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CFRTIFICATION NO.: 5305249-UC EXPIRATION DATE: 26/2008 ALTERNATE 1 DESIGNATED UST OPERATOR FOR TRIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSiM'SS NAME(1fdiffere.nt from above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Setvlce Technician ❑ I hj _p , INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdonal) DESIGNATED OPERATOR NAME: RELATION TO UST FACII;.ITY(Check One) BUSINESS NAME(Ifdif'erentfrom ahove): ❑ Owner C] Operator ❑ Employee DESIGNATED OPERATOR PHONE: ! 1 Cl Technician ext. ❑ Tb.ird-Party TNTFRNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: E4 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opalonal) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(If different from above): ❑ Owner C3 Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODJ:COUNCIL CERTIFICATION NO.: EXPIRATION PATE: I certify that, for the facility indicated at the top of this page, the iudividual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility ltlspections and annual facility employee training in accordance with California Code of Regulations,Title 23, Section 2715(c) through (1). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Tiana And riamanarivo for ConocoPhilli s Co. TANK OWNER TITLE: HSE Specialist OWNER _,. >?HONE: (510)245-5176 _ TANK OWNER SIGNATURE: H 411 DATE: 05/11/07 INSTRUCTIONS i 1. Report the narne(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC).ICC certification information is available on-line at:www.jeesafe.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. Undoes member agency jurisdictions and contact information are listed on-line at: www.unidoes,org/members/whoregulateswhat.html. Contact information for other local agencies within,California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/does/local agency_llst.xis. 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.unidocsorg 09/23/05 I