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n <br />Nor IV <br />CALIFORNIA HIGHWAY PATROL — FAk iLITIES SECTION <br />601 NORTH 7TH STREET <br />unip <br />CRAMENTO, CA 95811 "EV <br />f <br />RE BETH DEPAOLA <br />edepaola@chp.ca.gov <br />(916) 843-3817 OFFICE — (916) 322-3172 FAX <br />NOV 15 2010 <br />Designation of Underground Storage Tank (UST) Operator <br />UST Owner Statemed Compliance With UST Requirements <br />— <br />C <br />Facility Stockton Area Office <br />Facility <br />Name: <br />Permit #: <br />Facility 3330 N. Ad Art Rd <br />Address: <br />Phone: (209) 943-8666 <br />City: Stockton <br />Zip Code: 95215-2241 <br />Reason for Submitting this Form (Check One) ❑ Initial Certification ® Change of Designated Operator ❑ Certificate Renewal <br />Designated UST Operator(s) for this Facility <br />PRIMARY DESIGNATED UST OPERATOR <br />Designated <br />Relation to UST Facility (Check One) <br />Operator's Name: Raymond Friend <br />El ❑ Operator El Employee <br />Service Technician <br />❑ ®Third -Party <br />Business Name <br />Budifferent rom above : GEMS Environmental Management Services, Inc. <br />(IfDesignated <br />925 575-4833 <br />Operator's Phone #: ( ) <br />International Code 1057234 -UC Expiration Date: 1/15/12 <br />Council Certification #: <br />ALTERNATE 1 (Optional) <br />Designated Vonn Barton <br />Operator's Name: <br />Relation to UST Facility (Check One) <br />F1 Owner ❑ Operator ❑ Employee <br />❑Service Technician ®Third -Party <br />Business Name <br />I sii Brent rom above): GEMS Environmental Management Services, Inc. <br />Designated <br />Operator's Phone #: (925) 595-7789 <br />International Code 5259387 Expiration Date: 6/19/12 <br />Council Certification #: <br />ALTERNATE 2 (Optional) <br />Designated Steven Rojek <br />Operator's Name: <br />Relation to UST Facility (Check One) <br />ElOwner r_1 Operator El Employee <br />El Service Technician ®Third -Party <br />N <br />Business ame <br />I di e s N from above): GEMS Environmental Management Services, Inc. <br />Designated <br />Operator's Phone #: (925) 709-1944 <br />International Code 8024938 -UC Expiration Date: 9/02/11 <br />Council Certification #: <br />NOTIFY THE LOCAL REGULATORY AGENCY WITHIN 30 DAYS OF ANY CHANGES TO THIS INFORMATION <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated <br />UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility <br />employee training, in accordance with California Code of Regulations, Title 23, Sections 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) <br />applicable to underground storage tanks. <br />Beth DePaola <br />DATE: 11/01/10 <br />NAME OF TANK OWNER OR OWNER'S AGENT (Please Print) <br />OWNER'S PHONE #: 843-3817 <br />_(916) <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT <br />