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ITNDF,RC.-R4LI-INi)-SM4$tll?,4,GE 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 Olympian #427 ( ) FACILITY SITE ADDRESS 3300 Waterloo Road - CITY Stockton, CA -95205 REASON FOR SUBMITTING THIS FORM (Check one): Z Change of Designated Operator Update of ICC Certification Expiration Date(s) ArAnu "1VQ1f11VATGr►IMIrnPr12ATnR VOU TFIT.0 FACILITY Jr to altl rtq aY a "L' a v I N . - ---- - DESIGNATED OPERATOR NAME: Mike Zeman RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ® Service Technician ® Third -Party BUSINESS NAME (lfdierentfromabove): Petro-Teehz Environmental Services DESIGNATED OPERATOR PHONE: (707) 367-7020 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5249050 -UC EXPIRATION DATE: 11/15/2010 . a mv"isTA me , nVQF11 V A'rVn ItCT nPTi:12ATnR FnR THIS FACILITY(Ontional) DESIGNATED OPERATOR NAME: Dan Zeman RELATION TO UST FACILITY (Check One) ❑ Owner ❑Operator El Employee Service Technician Third -Party BUSINESS NAME (Ifdtfferentfrom above): Petro-TechZ Environmental Services DESIGNATED OPERATOR PHONE: (5530) 680-2905 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243781 -UC EXPIRATION DATE: 31i ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: 1 J f RELATION TO UST FACILITY (Check One) BUSINESS NAME (If differentfrom above): % ❑ Owner 171 Operator [Employee DESIGNATED OPERATOR PHONE: / ❑ 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 One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ - Third -Party BUSINESS NAME (If different from above): DESIGNATED OPERATOR PHONE: ( ) ext. 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 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: TANK OWNER TITLE: TANK OWNER SIGNATURE: INSTRUCTIONS OWNER PHONE: DATE: � /1616`7 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.iccssfe.org/e/certsearch.htmi. 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.unidoes.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at: www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_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. UN -062 - 1/1 www.unidocs.org 09/22/05