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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 Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) FACILITY NAME FACILITY PHONE CRLLC/76 #5447 ( 209 ) 478-1522 FACILITY SITE ADDRESS CITY 1469 E Hammer Ln Stockton REASON FOR SUBMITTING THIS FORM (Check One): ❑✓ Change of Designated Operator ❑ Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Byron Foy RELATION TO UST FACILITY (Check One) El owner ❑✓ Operator ❑ Employee El Service Technician ❑Third -Party BUSINESS NAME Wdiifferentfromabove): Convenience Retailers LLC DESIGNATED OPERATOR PHONE: ( 925 ) 765-8381 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5259415 -UC EXPIRATION DATE: 06/14/2013 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Raj/ Glaco azzi RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑✓ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (Ifdifferentfrom above): Convenience Retailers LLC DESIGNATED OPERATOR PHONE: ( 707 ) 575-1189 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8076413 -UC EXPIRATION DATE: 08/6/2012 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (If differentfrom above): DESIGNATED OPERATOR PHONE: ( ) ext. 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) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (Ifdiiferent from above): 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 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(5) 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: Convenience Retailers. LLC / Desianee: Allen Faass TANK OWNER TITLE: Compliance Manager OWNER PHONE: ( 925 ) 289-5286 TANK OWNER SIGNATURE: _�� DATE: 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 "California UST System Operators." 2. Submit this completed form to the local agency that regulates this f acility's USTs. Un idocs 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/ust/contacts/docs/local_agencv_list.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 -1/1 www.unidocs.org 09/22/05