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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(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> UPS - Stockton (209)944-5932 <br /> FACILITY SITE ADDRESS CITY <br /> 1532 N. Broadway Stockton, CA <br /> REASON FOR SUBMITTING THIS FORM(Check One): ❑Change of Designated Operator ®Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: pan Zeman RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdifferent from above): Petro TechZ Environmental Services ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (530)680-2905 ext. ® Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243781 EXPIRATION DATE: 2/14/2013 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(/fdzfferent froin above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME Qfdifferenlfromabove): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdifferenr from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 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(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 OWNERNAME: George Durkee <br /> TANK OWNER TITLE: Plant Engineering Area Manager OWNER PHONE: 510 633-4035 <br /> TANK OWNER SIGNATURE: DATE: <br /> INSTRUCTIONS <br /> 1. 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.htmi. Contact information for other <br /> local agencies within California is available at:www.swreb.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 />