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A SOV. UNDERGROUND STORAGE TANK SYSTEM O GAUVEMENTS OF DESIGNATED UST OPERATOR A" 201 ING OF AND COMPLIANCE WITH UST RE MENTIS 3 For nese by Unidocs Member Agencies or where approved by your Local Juris r 1 Authority Cited: Title 23,Div.3,Ch. 16 California Code of Regulations(CCR) rr FACILITY NAME FACILITY PHONE Tesoro/Shell#68150 (209)727-0823 FACILITY SITE ADDRESS Crry 13975 E. Hwy 88 Lockeford REASON FOR SUBMITTING THIS FORM(Check One): 0 Change of Designated Operator El Update of ICC Certification Expiration Date(S) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY, DESIGNATED OPERATOR NAME: Marla Guarnelil RELATION TO UST FACILITY(Check One) BUSINESS NAME(1l''dl„Qhrentfrom abow): Service Station Systems ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408)971-2441 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8158671-UG EXPIRATION DATE: 5/11/2014 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY onal DESIGNATED OPERATOR NAME: David Thomas RELATION TO UST FACILITY(Check one) BUSINESS NAME(IjVerenrfromabove): Service Station Systems ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (408) 971-2445 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5258-566-UC EXPIRATION DATE: 6/18/2014 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check Ore) BUSINESSNAME(lfdi terent kom above): ❑ Owner ❑ Operator Employe DESIGNATED OPERATOR PHONE: ( } ext. ❑ 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) BUSINESS NAME(U'dJ*rentfrom above): ❑ .Owner C] Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party 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: Steve Coulter TANK OWNER TITLE: EnvironmenWLCwplaince Administrator OWNER PHONE: 951 538-6895 TANK OWNER SIGNATURE: DATE: November 11,2013' 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.ieessfe.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-lime at: www.unidocs.org/members/whoregulateswhat.htmi. Contact:information for other local agencies within California is available at:www.swrcb.ca.goy/ewphomelust/contacts/doc s/local_Bgency_4st.xb. 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.onldomorg 49/22m f