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0 0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited: Title 23,Div. 3, Ch. 16 California Code of Regulations(CCR) <br /> FACILITY NAME CRLLC # 5448 FACI(209PHONE957-2900 <br /> FACILITY SITE ADDRESS CITY 1 <br /> 3202 W. Hammer Lane Stockton <br /> REASON FOR SUBMITTING THIS FORM(Check One): N Change of Designated Operator ❑Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME:Byron Foy RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdii erentfrom above):Convenience Retailers LLC ❑ Owner ❑ Operator ❑■ Employee <br /> DESIGNATED OPERATOR PHONE: (92 5) 7 6 5 - 8 3 8 1 xt. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.:5259415-UC EXPIRATION DATE:6/14/2013 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME:Raymond B. Giacopazzi RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdi,/ferentfrom above):Convenience Retailers LLC ❑ Owner ❑ Operator ❑■ Employee <br /> DESIGNATED OPERATOR PHONE: (707) 575-1189 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.:8076413-UC EXPIRATION DATE:8/6/1012 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdi,/jerent from above): ❑ Owner <br /> ❑ Operator E] Employee <br /> DESIGNATED OPERATOR PHONE: ( ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br /> Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations,Title 23,Section 2715(c)through (f). Furthermore,I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNERNAME: Convenience Retailers LLC / Designee: Allen Faass <br /> TANK OWNER TITLE: Compliance Mgr OWNERPHONE: ( 925 ) 884-0800 <br /> TANK OWNER SIGNATURE: ® DATE:7/15/2011 <br /> INSTRUCTIONS <br /> 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC).ICC certification <br /> information is available on-line at:www.iccsafe.org/e/certsearch.html.Search for"California UST System Operators." <br /> 2. Submit th is co mpleted form to th a to cal ag ency that regulates this f acility's USTs.Un idocs in ember ag ency j urisdictions an d <br /> contact info rmation are listed on-line at: www.unidocs.org/members/whoregulateswhat.html.C ontact i nformation f or other <br /> local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.xis. <br /> 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. <br /> UN-062-1/1 www.unidocs.org 09/22/05 <br />