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03/07/2008 13:09 FAX 19257561227 QUEST GSM 9 001 • 44 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 Statewide Petroleum Inc., dba Yosemite 76 (209) 823-7676 FACILITY SITE ADDR ESS CITY 1700 E. Yosemite Avenue Manteca REASON FOR SUBMITTING THIS FORM (Check One) Change of Designated Operator Update of ICC Certification Expiration Date(s) P1211MARy DESIGNATED UST nPF,RATOR FOR THIS FACILITY --- DESIGNATED ----------- -- -- - -- DESI(3NATED OPERATOR NAME Eric Wayne Garcia RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Ifdifferentfromabove): GDF Solutions, Inc. DESIGNATED OPERATOR PHONE: (9255) 292-0821 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5094004 -UC EXPIRATION DATE: 11/27/2008 Ar.TFRNATF I DESIGNATED UST OPERATOR FOR THIS FACILITY(Onttonat) DESIGNATED OPERATOR NAME: David Hinds RELATION TO UST FACILITY (Check One) ❑ o'er ❑ Operator ❑ Employee ❑ Service Technician ® Third -Parry BUSINESS NAME (Ifdifferent from above): GDF Solutions, Inc. DESIGNATED OPERATOR PHONE: (925) 292-0821 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5952437 -UC EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FUR TH15 F'AVILI'ITY (Optional) DESIGNATED OPERATOR NAME: RICK Davis RELATION TO UST FACILITY (Check One) BUSINESS NAME (Ifdifferentfromabove): GDF Solutions, Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE; (9255) 292-0821 ext. ❑ Service Technician ® Third -Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5266675 -UC EXPIRATION DATE: 8/18/2008 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: Stacy Hatton RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME Qf&fferentfromabove): GDF Solutions, Inc. DESIGNATED OPERATOR PHONE: (9255) 292-0821 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5295258 -UC EXPIRATION DATE: 9/22/2008 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. TANK OWNER NAME eel t=, o t2'.S ii- ? f 1�yi�% AL-, ! ,� � M �Ne � TANK OWNER TITLE: X j��,�,, OWNER PHONE: (209) 823-7676 TANK OWNER SIGNATURE: c - --` DATE: 'K :9 - 6{- eD 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.iecsafe.org/elecrisearch.html. Search for "California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidoes member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.html. Contact information for other local agencies within Califomia is available at: www.swrcb.cm.gov/cwphometusttcontacts/docs/locaLagency_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 vnm.unidocs.ore 09/22/05