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12/2 /'2009 11:59 FAX 17074466192 TANK-TEK IM 002/004 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 Juri�'diction Aulhority Cited.- Title 23, Div. 3, Ch. 16 California Code of Regularions (GC/) FACILITY NAME CRLLC #2705446 FACILITY PHONE 209-943-2082 FACILITY SITE ADDRESSCITY 1403 COUNTRY CLUB BLVD STOCKTON REASON FOR SUBMITTING T141S FORM (CbcckOne): ®Changc of Designated Operator Lj Update of ICC Ccrtil'ICLLtion Expiration Datc(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FAC[LI DESIGNATED OPERATOR NAME: Daniel Lawrence BUSINESS NAME (1fdii eren(from above): Tank -Tek Environmental DES IGNA ED OPERA'T'OR PI -ION 1,: (707)"6-6151 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8026453 -UC ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY ationali DESIGNATED OPERATOR NAME: Richard Thomas - BUSINESS NAME ((fd{Qcrcnrfroin above): Tank4ek Environmental Corp. DESIGNATED OPERATOR PHONE: (707)446-6151 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5254736 -UC ALTERNATE 2 DESIGNATED UST CIPP- RATnR FnIll THiR FArii ,IrTV /dU#i--- 11 RELATION TO UST FACILITY (Chock One) ❑ Owner ❑ Operator ❑ Employee ❑ Serviec Technician Third -Parry EXPIRATION DATE: 3/14/201 RELATION TO UST FACILITY ((leek Ow) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician 0 Third -Party EXPIRATION DATE: 1 DESIGNATED OPERATOR NAME; RELATION TO UST FACILITY ❑ Owner ❑ Operator ❑ Service Technician (Check Ono) ❑ T;mploycc ❑ Thir&Party BUSINESS NAME ((f d arent from above); DESIGNATED OPERATOR PHONE: ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO,; EXPIRATION DATE: V_L n l..n ak&V E JF7 PJ ^3 LW1U_7 V:O1 /1.NN:1me] WA 114a lv ra l:Ci an I I of r:1 LY 3 i m 1:w Y:1L suTTlrr, L7i DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check Ore) ❑ Owner ❑ Operator ❑ Employee ❑ Scrvicc Tcchnician ❑ Third -Party BUSINESS NAME (tfdzfferen(from above): 1313SIGNATED OPERATOR PHONE: 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($) 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, l understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANKOWNERNANE: TANK OWNER TiTI,E: OWNER PHONE: TANK OWNER SIGNATURE: 12, /6. ® Q INSTRUCTIONS I. 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.icessfe.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.unidocs.org/members/Whoregulateswhat-html. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/does/loesi_agency list.xls, 3. 23 CCR §2715(x) 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.nnidomorg 09/22/05