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C7 UNDERGROUND STORAGE TANK S'YSTE 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 Flyers #487 ( ) NA FACILITY SITE ADDRESS CITY 983 Moffat Blvd Manteca REASON FOR SUBMITTING THIS FORM (Check One): 0 Change of Designated Operator Update of ICC Certification Expiration Date(s) PRTjN1ARY nFRI(.NATF.n iIST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Jacob Lyon RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Scrvice "Technician ® Third -Party BUSINESS NAME(lfdfferentfronmaboie): LG Environmental DESIGNATED OPERATOR PHONE: (530) 513-7828 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.; 8052304 -UC EXPIRATION DATE: 6/2/2012 AT.TERNATE i i ESIGMATED TT.ST OPERATOR FOR THIS FACILITY(Outional) DESIGNATED OPERATOR NAME: Clent Gagnler RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESSNAtv1E(lfdifferentfion:aboti-e): LG Environmental DESIGNATED OPERATOR PHONE: (530) 521-6818 ext, INTERNATIONAL. CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 9/29/2012 A L TIe..RNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME- RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (If different from aboie): DESIGNATED OPERATOR PHONE: ( ) ext, INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPi>(AT[OWbA Al TPr2VrATE i DR.RYV_ VATRn TPR I' OPF,RATOR FOR THIS FA Lal) DESIGNATED OPERATOR NAME.• RELATION TO UST FACILITY (Check One) Milner ❑ Operator ❑ Employee ❑ Service Tec i ian ❑ Third -Party E N t BUSINESS NAME (Ifdif)erent front above); DESIGNATED OPERATOR PHONE: ) ext INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: ENTR[ N DATE: 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: Amanda Appelt TANK ONArNER TITLE: _Environmental M TANK OWNER SIGNATURE: INSTRUCTIONS OWNER PHONE: (530) 885-0401 DATE: May 16, 2012 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:)vww.iecsafe.org/e/certsearch.html. Search for "California 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.iiiiidoes.org/meiiibet•s/evlioregulateswiiat.litnli. Contact information for other local agencies within California is available at: wNiw.swreb.ca.gov/eivphonne/fist/coiltacts/does/local—agency llst.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 winv.unldocs.m•g 09/22/05