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0 0 RECEIVED UNDERGROUND STORAGE TANK SYSTEM 1 2013 OWNER STATEMENTS OF DESIGNATED UST OPERATOR&0 UNDERSTANDING OF AND COMPLIANCE WITH UST REQIHRVIRONWNTAL For use by Unidocs Member Agencies or where approved by your Local JurisdictiodiEALTH DEPARTMENT Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Ln FACILITY SITE ADDRESS CITY �R�U� F�c 5 REASON FOR SUBMITTING ORM(Check ane): of DesignatedOperator Update ®f ICC Certificati®n Expiration Dat,(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY RELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: JeramyCurnmins BUSINESS NAME(Ifdifferentftom above): 13Z Service Station Maint., Inc. E] Owner [] operator [] Employee DESIGNATED OPERATOR PHONE: (916) 371-2380 ext. L_J Service Technician Third®P RA420 INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8019661- U C EXPITION DATE: /14/ 14 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FA — DESIGNATED OPERATOR NAME: Kelvin Cruz RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferenffrom above): BZ Service Station Maint., Inc. 11 Owner E] Operator El Employee DESIGNATED OPERATOR PHONE: (916) 371-2380 ext. [] Service Technician 0 Third-Party RA28 INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8016282 UC EXPITION DATE: 10/ /2013 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) — DESIGNATED OPERATOR NAME: James Willams RELATION TO UST FACILITY(Check One) BUSINESS NAME(07differeniftom above): BZ Service Station Maint., Inc Owner [] operator [1 Employee DESIGNATED OPERATOR PHONE: (916) 371-2380 ext. Service Technician 0 Third®p INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252274 - UC EXPIRATION DATE: 6/4/2015 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Rhome hi ns RELATION TO UST FACILITY(Check One) BUSINESS NAME Qfdifferentfrom above): BZ Service Station Maint., Inc Owner [] Operator [] Employee DESIGNATED OPERATOR PHONE: (916) 371-2380 ext. service Technician Z Third®P INTERNATIONAL CODE COUNCIL CERTIFICATIONEXPIRATION DATE:NO.: 5244364-uc 2-07-2014 1 certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated LIST 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: W t C%Vk—t TANK OWNER TITLE: a�–k OWNER PHONE: (7,t)c) q7cK 62 _ TANK OWNER SIGNATURE: DATE: I Z-7113 INSTRUTIONS L 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.icesafe.orgle/certsearch.htmi.Search for"Califomia 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/whoregulateswhathtmi. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/usVcontacts/does/local–agency–list.xls. 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