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07/13/2007 09:51 FAX 17074466192 TANK-TEK 12002/002 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 Exxon ( ) FACILITY SITE ADDRESS CITY 1399 E. Yosemite Ave Manteca REASON FOR SUBMITTING THIS FORM (Check One): ® Change of Dcsignaied Operator U Update of ICC Cord ication Expiration Date(s) PRIMARY DESIGNATED UST OP: DESIGNATED OPERATOR NAME: Lou THIS FACILITY ppe Rooms BUSING.SSNAME(Ifdfferenefromabove): Tank -Tek Environmental Corp. DESIGNATED OFERRATOR PHONE: (707) 446.6151 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5248336 -UC AT TYRNATr.. t nF..Qr.NATRn IIST OPERATOR FOR THIS FACILITY (Optional) RELATION TO UST FACILITY (Check One) ❑ Owner Q Operator ❑ Employee ® Scrvicc Technician ❑ Third -Party EXPIRATION DATE: 12/16/2008 DESIGNATED OPERATOR NAME: Robert (Rob) Neimeyer RELATION TO UST FACILITY (Check One) ❑ owner ❑ operator ❑ Employce ® Service Technician ❑ Third -Party BUSINESS NAME (ifdifferenefrom above): Tank -Tek Environmental Corp. DESIGNATED OPERATOR PHONE: (707) 446-61$1 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5248067 -UC EXPIRATION DATE: 12/28/2008 ALTCIZNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATE/] OP>✓RATOR NAME' RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Parry BUSINESS NAME (Ifd&renefrom above). DESIGNATED OPERATOR PHONE: ( ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DACE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee L]Service Tccltnician L] Third -Party BUSINESS NAME (Ifd(jjerenefrom above): DESIGNATED OPERATOR PHONE: ( )ext. 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: 1_' ._s TANK OWNER TITLE: ?' 7 f ;"'? -r, �t �— OWNER PHONE: TANK OWNER SIGNATURE: � `)�„, I - � �� : � DATE: 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-line at: www.iccsofe.org/e/certscarch.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.unidocs,org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs/local agency_list.xls. �. 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.unldocs-org 09/22/05