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DEC-16-2011 14°20 SERVICE STATION 14089388888 P.02 <br /> J. <br /> DEC 1 6 2111 t <br /> caner Statements of Designated Underground Storage Tank' rator <br /> ,_,•a <br /> and UndersUnding of and Compliance with UST eq i � Fr <br /> Footlity Name: Unocal Facilsy IC#' 25SUG <br /> f� <br /> Fudiny Address' 2701 Maroh Ln. Reason for Submitting this Form <br /> Stockton, CA 95219 M Change of DwlgnxMd Operator <br /> Pocky P 209 473-7337 M opiate Canlhesb Expirption We <br /> Deo ttflled UST Operate s}for this P <br /> Primary r <br /> Designated Operator's Name: Sigan Lundlett Relation to LIST Facily ON) <br /> !i <br /> Rusirs"Name(I'tdU efflot above), Servicer Station systems ❑ owner Q operator t7 Employee <br /> o"Ignmted Operator's Phone•#: 408 971-2446 M 8erVft Toahnician M Third-Parr <br /> Intsmagonal Code Council GWdflMIQS P 8001468-UC GMIMOOM Date: 6/16/13 <br /> Alternate I MPdomO <br /> Designated 0"FE 's HOMO.' Ryan Casey aeration to UST FeoftCheck 0" <br /> Business Name INd/ttbrvnf ftn segue); sBrVIC@ StAtloPl Systems D Cerner p Operator ❑ Ernpioyea <br /> Designated Operatpr's Phone 9-1 408 971.2445 3 Serdlaa TeahnidPart <br /> en M Thlyd- y <br /> Intemationsl Cade Cwidi C401catlon A 8057654PUC Expirallon Data: 9/16/12 <br /> Alternate 2(Optiona�) <br /> Designated opersteee Name, Dave Thomas ftelatlon to u8T Fearhyclwk One) <br /> Business Mame(ff crftr9M rmm,°beam); Service Station Systems D owner a operator O amp"a <br /> Deav4 ted Operators Phone#; 499 971 2445 M Service Tdohnigian Cl Third-Party <br /> triftmi tonal Code Council Cattffl00114n* 5258566-UC Expiration Dow 712M2 .f <br /> Tank Owner <br /> I certify that, For the faelilty Indicated at the top of thls page, the individuat(s) listed above will serve as Designated <br /> UST Operator(s). The individual(a)will conduct and document mord hly itty inspections end annual facility <br /> employee training, In accordance with California Ctddo of Regulations, title 23, section 2715(c)-( . <br /> FuMermore, 1 uridenstand and am in compliance with'the requirements (statulse, regulatIons,and local <br /> ordinances) applicable to rind round storage tanks, <br /> Name of tank owner(Pleas rant): l <br /> Signature oftank owner: <br /> Data: Ownses Pholnrre :C <br /> A\ G: A <br /> 1)Submit this completed form to the Local Agency (NOT the State Water ureas control Board) <br /> By January 1,2008,The al atgency ast is availgblle at: www.waterboards.ca.gov/ueVoonWts/cupa_agys,htrni. <br /> 2)Notify the Local Agency of any changes to this Information within 30 Days of the change, <br /> 5 ' <br />