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10/27/2010 15:23 12098341096 TRACY BLVD SHELL ' PAGE 01/01 UNDERGROUND STORAGE TANK SVS'TEM OWNER STATEMENTS OF DESIGNATED UST OPERATORkMW 7 UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTP For use by Undoes Member Agencies or where approved by your.Local Jurisdictaor! Authority Cited.- rifle 23, I)iv. 3, Ch. 16 California Code of,Regulations(CCR) FACILITY NAME FACILITY PHONE. Tracy Shell ( ) FACILiTY SITE ADDR&SS CITY 3725 Tracy Blvd., Tracy CA 95377 REASON FOR SUBMITTING THJS FORM(Check One;): ®Change Of Ocsignated Operator Update of ICC Certification Expiration natc(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATFD OPERATOR NAME: Brian Dunahay RELATION TO U5TTACILITY(Check One) BUSINESS NAME(/fAferentfromabove): EPIC Compliance Systems ❑ Owner ❑ Operator ❑ Employee DE51GNATED OPERA'fOK PHONE: (888)700-EPIC extService Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.; 8021436-UC EXPIRATION DATE: 12/6/2010 ALTERNATE i DESIGNATED UST OPERATOR FOR THIS FACILITY( , trona!) DESIGNATED OPERATOR NAME: Alvin L Milburn RELATION TO UST FACILITY(Check One) BUSINESS NAME(lfdf,8'erentfromabove): EPIC Compliance Systems ❑ Owner ❑ Operator ❑ Employee DESIGNATEDOPE.RATORPHONE: (888)700-EPIC eXt. El Service Technician ® Third-Party INTF,RNATIONAI,CQDF,COTJNCIt.CERTIFICATION NO.: 0878949- UC EXPIRATION DATE: 12/6/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS]FACILITY(Optdonal) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(lf differeni from above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PFIONE: ext- ❑ Service Technician ❑ Third-Parry 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(ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE; ( > ext. ❑ Service TechnicianF71 `third-Iaarty INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: I certify that, foir the facility indicated at the top of this page, the individual(s) listed above will serve as Designated IJST Operators) The individual(s)will conduct and document monthly facility inspections and annual facility employee training in accordance witb 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: TANK OWNER TITLE: _ OWNED PHONE: TANK OWNER SIGNATUDATTE: /0 INSTRUCTIONS I. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(TCC). ICC certification information is available on-line at:www.icesafe.org/e/certsearch.btml. 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/whoregulateswhathtmi. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphomne/ust/contacts/docsAocal_agency_listxls. 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.unidoeLorg [19!22105