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UINDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING OF AND COMPLIACNE WITH UST REQUIREMENTS <br />Authority Cited: Title 23, Div 3, Ch 16 California Code of Regulations (CCR) <br />Facility Name:ARCO AMPM <br />Facility Phone #:209-466-6633 <br />Facility Address: 130 S WILSON WAY <br />City:STOCTON <br />Reason for Submitting this Form (Check One) ❑ Change of Designated Operator ® Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />Business Name: BZ Service Station Maintenance, Inc. <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician x Third -Party <br />Address: 1041 Triangle Ct, West Sacramento, Ca 95605 <br />Designated Operator's Phone #: 916-371-2380 <br />Designated Operator's Name <br />ICC # <br />Expiration date <br />Derreq Knaules <br />8342108 -UC <br />10/5/17 <br />James Williams <br />5252274 -UC <br />4/7/17 <br />Jeff Brown <br />5257058 -UC <br />5/20/17 <br />Jeramy Cummins <br />8019661 -UC <br />7/28/18 <br />John Li <br />8411443 -UC <br />5/21/18 <br />Rhome Desbiens <br />5244364 -UC <br />1/27/18 <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, section 2715(c) — (f). Furthermore, I understand and am incompliance with <br />the requirements (statutes, regulations, and local ordinances) applicable to underground storage <br />tanks. <br />TANK OWNER NAME: Parminder Mashiana <br />TANK OWNER TITLE: secretary OWNER PHONE: 916-952-6337 <br />TANK OWNER SIGNATURE: <br />DATE: 2/10/2017 <br />1. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC <br />certification information is available on-line at: www.iccsafe.ore/e/certsearch.html. Search for `California UST System <br />Operators." <br />2. Submit this completed form to the local agency that regulates this facility's USTs. <br />3. 23 CCR 2715(a) requires that you notify the local agency of any changes to this information within 30 fays of the date <br />of change. <br />