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UNDEPROUND STORAGE TANK SfM 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 Cite& Title 23, Div. 3, Ch. 16 California Code ofRegulations (CCR) FACILITY NAME FACILITY PHONE Olympian #427 DESIGNATED OPERATOR PHONE: (707) 367-7020 ext. FACILITY SITE ADDRESS CITY 3300 Waterloo Road Stockton, CA 95205 REASON FOR SUBMITTING THIS FORM (Check One): Z Change of Designated Operator 0 Update of ICC Certification Expiration Date(s) DESIGNATED OPERATOR NAME: MikeZeman RELATION TO UST FACILITY (Check One) ❑ Owner [] Operator ❑ Employee Service Technician Third -Party BUSINESS NAW (Idifferentfrom above): Petro-Techz Environmental Services . DESIGNATED OPERATOR PHONE: (707) 367-7020 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5249050 -UC EXPIRATION DATE: 11/15/2010 DESIGNATED OPERATOR NAME: Dan Zeman RELATION TO UST FACILITY (Check One) El owner 0 operator E] Employee Service Technician Third -Party BUSINESS NAME (Idtfferentftom above): Petro-Techz Environmental Services DESIGNATED OPERATOR PHONE: (530) 680-2905 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243781 -UC EXPIRATION DATE: Pending ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO AO UST FCILITY (Check•ne) 11 Owner D Operator nEmployee ■ Service Technician E] Third -Party BUSINESS NAME Qfdifferentftom above): DESIGNATED OPERATOR PHONE: ext. . •11 1 ill 0 Fm EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) E] Owner E] Operator El Employee El Service Technician ❑ Third -Party BUSINESS NAME (If differentfrom above): DESIGNATED OPERATOR PHONE: ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: wMaviumm • TANK OWNER SIGNATURE: DATE: INSTRUCTIONS 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.iccsafeorgle/cerbearch.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.unidocs.org/members/Whoregulateswhat.htmi. Contact information for other local agencies within California is available at: www.swrcb.ca,gov/cwphome/ustleontacts/does/localagencyjist.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 rommaidoesorg 09/22/05