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0 0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations <br /> FACILITY NAME FACILITY PHONE 60 <br /> CRLLC 5446 (209) 943-2082 <br /> FACILITY SITE ADDRESS CITY MAY 17 N13 <br /> 1403 Country Club Blvd Stockton <br /> REASON FOR SUBMITTING THIS FORM(Check One): ® Change of Designated Operator ❑Update of ICC Certific <br /> HEALTH DEPAATA <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: Eva Traylor ELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdiiferentfromabove): Convenience Retailers, LLC ❑ Owner ❑ Operator N Employee <br /> DESIGNATED OPERATOR PHONE: (909)455-2275 ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: UC-8200889 EXPIRATION DATE 4/6/15 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: ELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdifferentfrom above): ❑ Owner ❑ Operator® Emplo e <br /> ext. ❑ Service Technician ❑ Third-Party <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY ftfionao <br /> �CQ��M A�U-Q �9 ATOR NAME- I A TION 4:0 I;ST-FACILITY(Ghoi;k 004- <br /> ❑ Ownernn Operator ❑ Employee <br /> 1:1 Service Teg ician ❑ Third-Party <br /> BUSINESS NAME(Ifdi�%, rentfxom above); ❑ Owner nn Operator ❑ Employee <br /> E:1 Service T,Hnician ❑ Third-Party <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br /> Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations,Title 23, Section 2715(c) through (f). Furthermore, I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNER NAME: Convenience Retailers, LLC / Designee: Allen Faass <br /> TANK OWNER TITLE: Compliance Manager OWNER PHONE: (949) 289.5286 <br /> TANK OWNER SIGNATURE: DATE: April 4, 2013 <br /> INSTRUCTIONS <br /> I. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification <br /> information is available on-line at:www.iccsafe.org/e/certsearch.htmi.Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and <br /> contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.html. Contact information for other <br /> local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.xis. <br /> 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. <br /> UN-062-1/1 www.unidocs.org 09/22/05 <br />