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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs lviember Agencies or inhere approved by your Local Jurisdiction Awhority Cited: Title 23,Div. 3, Ch. IG California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Flyers #487 ( ) NA FACILITY SITE ADDRESS CITY 983 Moffat Blvd Manteca RF,ASON FOR SUBMITTING THIS FOR\&I(Check One): ®Change of Designated Operator ❑Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Jacob Lyon RELATION TO UST FACILITY(Check(bre) BUSINESS NAME(Ifcliiferentfromabove): LG Environmental ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (530) 513_7828 Ext. ❑ Service'fechnician ® Third-Party INTEItNA'rIONAi.CODE COUNCIL CERTIFICA'FION NO.: 8052304_UC EXPIRATION DATE: 612/2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Clent Gagnler RELATION TO UST FACILITY(Check One) BUSINESS NAtvIE(lfdierertt fiona above): LG Environmental ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (530) 521-6818 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 9/2912012 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Jf different from above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check Orae) BUSINESS NAME(Ifdifferearfrom aborej: ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION 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 011PIO)'ee training in accordance with California Code of Regulations,Title 23,Section 27I5(e) through(f). Furthermore,I understand and ani In compliance with the requirements(statutes,regulations,azul local ordinances) applicable to underground storage tanks, TANK OWNER NAME: Amanda Appelt TANK OWNER TITLE: Environmental Manager ONArNER PHONE: (530) 885-0401 TANK OWNER SIGNATURE: CDATE: May 16, 2012 INSTRUCTIONS 1. Report the nalne(s)of the Designated UST Operator(s) as registered with the International Code Council(ICC). ICC certification information is available on-line at:tivww.icesafe.org/e/eertseareh.lttml.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: wii'w.tiiiidoes.org/tnenibershvlioregulateswltat.litrIlt. Contact information for other local agencies within California is available at:wwiv.swrcb.co.govlewpliotne/trst/contacts/cloes/local_ageney_list.xis. 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. Lr\-Ob2-1/1 www.unldocs.org 09/22/05