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UNDERGROUND STORAGE TANK SlS�� V�a2D OWNER STATEMENTS OF DESIGNATED UST OP UNDERSTANDING OF AND COMPLIANCE WITH UST R"iJlfWNTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of RegulahbM?CJWE1V V HEALTH PEPAA17/cco„j., FACILITY NAME FACILITY PHONE CHP Site - Stockton Uq , q wb FACILITY SITE ADDRESS CITY 3330 N Ad Art Road Stockton REASON FOR SUBMITTING THIS FORM (Check One): ® Change of Designated Operator ® Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Nikola Zagorov RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Ifdierentfromabove): EPIC Compliance Systems DESIGNATED OPERATOR PHONE: (888) 700 -EPIC ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5264361 — UC EXPIRATION DATE: 7/12/2009 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Brian Dunahay RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Ifdiferentfrom above): EPIC Compliance Systems DESIGNATED OPERATOR PHONE: (888) 700 -EPIC ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8021436 -UC EXPIRATION DATE: 12/06/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: Al Milburn RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Ifdierentfromabove): EPIC Compliance Systems DESIGNATED OPERATOR PHONE: (888) 700 -EPIC ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 0878949—UC EXPIRATION DATE: 12/6/2010 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee . ❑ Service Technician ❑ Third -Party BUSINESS NAME (If dii Brent from above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: I certify that, for the facility indicated at the top of 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. em TANK OWNER NAME: W_+� TANK OWNER TITLE: OWNER PHONE: TANK OWNER SIGNATURE: DATE: `l o INSTRUCTIONS 1. 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.iccsafe.org/e/certsearch.htmi. 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/whoregulateswhat.html. Contact information for other local agencies within California is available at: www.swrcb.ca.gov/cwphome/ust/contacts/does/local_agency_list.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. UN -062 -1/56 www.unidocs.org 09/22/05 -JV