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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 Food Mart Gasoline (209) 941-2264 FACILITY SITE ADDRESS CITY 2185 Fremont Street Stockton, CA. 95205 REASON FOR 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: Mark R. Fairbanks RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (If dierenlfromabove): Fairbanks Environmental Consulting DESIGNATED OPERATOR PHONE: (209) 263-2174 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 55243795 EXPIRATION DATE: 9/29/2013 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (Ifdifferentfrom above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (Ifdifferentfrontabove): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (If different from 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. TANKOWNERNAME: Dahni Ram Salhan / Ste` ,, TANK OWNER TITLE: Operator Manager�,v e ��/,,y ZZ-'- OWNEIZ ISI IONS: (209) 941-2264 TANK OWNER SIGNATURE: 16 q�h E % DATE: October 18, 2011 i 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 at: www.iccsafe.org/e/certsearch.htmi. Search for "CalifoiMia UST SysteTnOperators." 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/whoregulateswhat.htmi. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.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.unidoes.org 09/22/05