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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENT 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) I FACILITY NAME FACILITY PHONE CRLLC/76 #5446 209 ) 943-2082 FACILITY SITE ADDRESS CITY 1403 Country Club Blvd Stockton DESIGNATED OPERATOR PI IONE: ()ext. DESIGNATED OPERATOR NAME: Atila Fernandez RELATION TO UST FACILITY (Check One) ❑ Owner [] Operator Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (Odifferentfrom above): Convenience Retailers, LLC ... . ...... DESIGNATED OPERATOR PHONE: ( 510 ) 774-5066 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO,: 809291 O -UC EXPIRATION DATE: 12/22/2012 v v , nxT . mw T% i PCT r% D v p A rn D vn D r u i c V A 9- 11 _T'rV ff),IM . .1) W.TI I . , A PAMINNI � ' a I M I wwrin, i fill 1770 � I IM NOVA DESIGNATFD OPERATOR NAW RELATION TO UST FACILITY (Check One) owner C1 operator FZI Employee n Service Technician 0 Third -Party BUSINESS NAME (ffilifferentfrom above): Convenience Retailers, LLC -J E] Owner [j Operator 0 Employee DESIGNATED OPERATOR PHONE: ( 415 ) 990-6824 ext. 11 -- INTERNATIONAL C66ETOI�RCIL CERTIFICATION NO.: 8076413-U ............ . A I AVO W.TI I . , A PAMINNI � ' a I M I wwrin, i fill 1770 � I IM NOVA DESIGNATFD OPERATOR NAW RELATION TO UST FACILITY (Check One) DESIGNATED OPERATOR NAME: E] Owner [j Operator 0 Employee BUSINESS NAME (Indifferent from above): n Owner 0 Operator 0 Employee E] Service Technician El Third -Party DESIGNATED OPERATOR PI IONE: ()ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ff1r.1TMr%TrA_r.qrV1r MMAY01! a V.4 I LIS MI. I - RELATION TO UST FACILITY (Check One) DESIGNATED OPERATOR NAME: n Owner 0 Operator 0 Employee BUSINESS NAME (Ifilifferentfrom above), Ej Service Technician ❑Third -Party 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 inwual(s) listed above will serve as Designated UST Operator(s). The inIual(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. TANKOWNERNAME: Convenience Retailers, LLC /Designee: Allen Faass TANK OWNER TITLE: Compliance Manager OWNER PHONE: ( 925.. ) 884-0800 Ilwyalrall 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.iccsafe.org/e/certsearch.htmi. Search for "Califomia UST System operators." 2. Submit th is completed form to th c to cal agency that regulates this f acility's USTS. Un idocs m ember ag ency j urisdictions an d contact info rmation are listed on-line at: www.unidoes.org/members/whoregulateswhat.htmi. C ontact i nformation f or other local agencies within California is available at: www.swrcb.ca.gov/cwphome/ust/contacts/does/local—agencyjist.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 - III www.unidocsorg 09/22105