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0 <br />0 <br />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 (CCR) <br />FACILITY NAME <br />FACILITY PHONE <br />H & M MARKET <br />(209) 838-3971 <br />FACILITY SITE ADDRESS <br />CITY <br />2501 JACKSON AVE. <br />ESCALON, CA. 95320 <br />REASON FOR SUBMITTING THIS FORM (Check One): Change of Designated Operator Z Update of ICC Certification Expiration Date(s) <br />PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br />DESIGNATED OPERATOR NAME: KAREN ARNAIZ <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />BUSINESS NAME (.(f d(ljerent from above): <br />DESIGNATED OPERATOR PHONE: (209) 518-4836 ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 80322955 -UC <br />EXPIRATION DATE: 6/20/2011 <br />AT.TF.RNATF. t DF.Sif NATF.D UST OPERATOR FOR THIS FACILITY(Ondonal) <br />DESIGNATED OPERATOR NAME: <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />BUSINESS NAME (itdl/ferent from above): <br />DESIGNATED OPERATOR PHONE: ( ) ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: <br />EXPIRATION DATE: <br />ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) <br />DESIGNATED OPERATOR NAME: <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />BUSINESS NAME (If dl(ferent from above): <br />DESIGNATED OPERATOR PHONE: ( ) ext <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: <br />EXPIRATION DATE: <br />ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) <br />DESIGNATED OPERATOR NAME: <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />BUSINESS NAME (lfdl(ferentfromabove): <br />DESIGNATED OPERATOR PHONE: ( ) ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: <br />EXPIRATION DATE: <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(e) 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: <br />TANK OWNER TITLE: C UA <br />E COORDINATOR OWNER PHONE: (209) 577-6000 <br />TANK OWNER SIGNATURE: WIC DATE: July 30, 2009 <br />INS CTIONS <br />I . Report the name(s) of the Designa d 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.swreb.ca.gov/cwphomelust/contacts/does/local agency_list.xis, <br />3. 23 CCR §27I5(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 - I/I www.unidocs.org 09/22/05 <br />