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04/13/2009 15:24 FAX 17074466192 <br />TANK-TEK <br />E <br />UNDERGRIC)UNT STORAGE TANk SYSTEM <br />OWNER STATEMENTS OF DESIGNATED LST OPERATOR ANIS <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br />For use by F,`nidiors A vnher .pawns nr wb&re approved bV,})oup legal ✓urisdretron <br />,Aad roriq• Ciread Tile 23, DA, 3, Ch. `6 Cultfonda Codd q%RCgR1atioets <br />IA 004/004 <br />FM: RXT- NAM FACI1, MY PFit,'I.N' F, � <br />CPJ-LC 027 209-967-2900 + <br />FACILITY SRE ADORESS CITY <br />i 3202 W. HAMER LANE STOCKTON � <br />i REASON FdR SL18SIflTING THIS FORtiI lChrtk amr. Ll Chane of IIcaiGnated Operator L'pdut of ICC Ccrtitit®Lon Espirstion Datels) <br />o„-•uuaxecuvreatoiuicrnuva %fu(jeXL <br />PrMIPIATIONAL CODE COUNCIL CERTIFICA11ON NO.: 8026$63 -UC <br />Al WMATE i DFSIMAT]E.n 11-T APF1tdTing FARM UM FArn TTY esa.rc,...4n <br />RELATION TO UST FACRSfY (Check Oo o <br />❑ Owner ❑ Opernaor ❑ Employer <br />❑ Service Tcchaician ® Tli;m.Partp <br />INY.VP <br />ORMIGNATEO OPMATOR NAME' Richard Thomas <br />WELATION CU UST FACILITY IChrc:Onel <br />❑ Owner 0 0pcnuor ❑ Employee � <br />❑ SaviorTmlinicim Tbird-P$ty <br />111131NEwNAmEtfldlftfi—asasa: Tank --Tek Environmental Corp. <br />M OPr'XATMP> O?W: (707) 151 <br />MmMT101U►L CODE COUNCIL CMT lF1CAT NO, . 52 4735-UCTION <br />D:TR, 1M20 <br />�rsi� ►fii�*�I�Jx`�tr} Lylxll��7�i���l ryr•7 Il.1VjJ"141a <br />DumATmQrERATORNAMF Michael (Mike) Lawrence <br />RELATION TO UST FACILITY (CheekOtvl <br />❑ Owner ❑ Opmw ❑ Cmployec <br />❑ Scrvicc Technician ® Third -Pam <br />euSLvess'SAME of d*rMrfiVw ®asm)! Tank Tek Environmental Corp. <br />DBI0rNATGf1 OPERATOR PWKE- (707) 446.6131 Olt, <br />N' EKKATMXALCQDE COUDIM CERTIFICATION• iN0.: 10a103 -UG <br />'DATE. 10/12/2009 <br />EF 4s -5P V.'na*it]:fA[+rY /.ti11:4'ILI-1 iall WNIf-'%to] #r#l:itY;1LYYTafflrri►'drle��7'77 <br />pulGxATMOMATOR NAME- Virginia Fulgaro <br />RELAVON TO VST FACIL" tCAvek 0ow1 <br />❑ ORnsr ® Owam ❑ Enq,)%rc <br />®Swire 'I'eehnielgit Third -Party, <br />BUSINESS NAMEMfi—abovo- Tank -Tek Environmental Corp. <br />9 TFD OPE-RATOR PHONE. 1707) "6-6151 <br />INMNATIONAL CODE COUNCIL. CERTU ICA31ov \'0• 63 UC <br />I MCPIRATION DATt3• 11/17/2009 <br />1 certify mat, for the facility indicated at the top of this pagan the iodividoal(s) listed above will serve as Designated UST <br />Qpmwr(zy. The indiroiduaks) will conduct and docan=1 monthly fac@icy inspections and annua l facility employee training. <br />in seeosa3ance with Caliromis Code of Replations. Title 23� Section 2715(c) through (f). Furthermore. 1 understand and pm <br />in compliamx with the requirements (staautes, Mix1ations, And local ordinances)applicable to underground storage tanks. <br />TANK OWNER NAME: <br />T.4hIK OWNER TITLE: / � �� f!laar�% O%VNER PHONE:W(Cf?,�) <br />TANK 0WNER S10NATURE_ %z/_t_ UATE: /D- Aff <br />Ir � ur" <br />1, Repot the name($) of the Designited USI' Operawr(s) w registerud with the International Codc Council ILC;(;p, lC"r, ceniile:nion <br />information is availabic on-line sr wxw_iecaaTe org'eJcertsearch.html. Search Lor" California L.NT System Operators," <br />2, Submit This eomplered form to the local agency That rcr alaics this Ncility'. USTs. linidocs member agency jurisdiction% anti <br />contact Infomaxion are fisted on-line = wwv%,.uslidocs.orWmembessiwhoregulsmwhat.htmi. Contact information tier othtr <br />loud agencies %ilhin California is available atw-a-w.sw-reb.ca.govicwphomeAk5VCOOIacWdocsAoeal_agtnCy_IiSt.sls, <br />3. 23 CCR §2715(a) requires That you notitd the Instal agency of ar.y changes ro this Iniarmarion within 30 &}s of :he detc of ch,^.nge. <br />I'1 -U6-' • UI <br />tin a.un1di <br />t <br />