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JUL-24-200e 11:24A FROM: 70:46e3433 P.1 M .ev3/I - 31/.3,3 UNDERGROUND STORAGE TANK SYST' OWNER STATEMENTS OF DESIGNATED UST OPE go UNDERSTANDING OF AND COMPLIANCE WITH UST REQU11RCRE*4kz For use by Unidoes Member Agencies or where approved by your Local Jurisdictiod1jL2 4 008 Authority Cited.- Title 23, Div. 3, Ch. 16 California Code ofRegulations(CCR) 2AN FACILITY NAME FACILITY PHONE EATVIZIUIIV Cou/v� Country Mart Diesel & Gas 76 (209) 914-5583 1'-'ALrH 01VUEN,r FACILITY SITE ADDRESS CITY 34243 South Crisman Tracy REASON FOR SUBMITTING THIS FORM(Check One): C]Change of Designated Operator Z Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAW: Aneil Chand RELATION TO UST FACILITY(Check One) BUSINESS NAME(tf d(fferentfrom above): Pinnacle Fuel Compliance Services El Owner 0 Operator El Employee DESIGNATED OPERATOR PHONE: (408) 206-9840 ext. i_j Service Technician JE Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5119959 - UC EXPIRATION DATE: 7/11/2010 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdoffdj _ DESIGNATED OPERATOR NAME: Matthew Hasley RELATION TO UST FACILITY(Check One) BUSINESS NAME(1fdoerentfrom above): Pinnacle Fuel Compliance Services E) Owner [I Operator ❑ Employee DESIGNATED OPERATOR PHONE: (209)603-7127 ext. E] Service Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 6259431 - UC EXPIRATION DATE: 7/11/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME Wdifferentfrom above): 0 Owner 0 Operator 0 Employee DESIGNATED OPERATOR PHONE: ( ) ext. 0 Service Technician E3 Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(opilanal) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(If differentfrom above): C1 owner El Operator 171 Employee DESIGNATED OPERATOR PHONE: ( ) ext. 0 Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.; EXPIRATION DATE: I certify that, for the facility indicated at the top or 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. —a\ TANK OWNER NAME: :ngA1q7, -r S S4AIJ5,41,t ' TANK OWNER TITLE: SA.VS1 ^1535 T WA147& 0AL I-'/ OWNER PHONE: (202) 914-5583 —$ TANK OWNER SIGNATURE:— DATE, 2.3- OX INSIRUCTLQDLS i. 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.icesafe.org/etcertsearcb.htmi.Search for"California LIST 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/Whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.swreb.ca.gov/cwphometustleontacts/does/local—agencyjist.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. Pinnacle Fad Compliance Services,Inc.