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® UNDERGROUND STORAGE TANK SNI R, FEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited, Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) FACILITY NAME CHP Site - Stockton Area office FACILITY SITE ADDRESS 3330 N. Ad Art Road REASON FOR SUBMI"I'TING "I'HIS FORM (Check One) FACILITY PHONE 209-943-8666 CFFY Stockton Change of Designated Operator PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DI.SICNArr:D OPl RA'FOR NAME: Nikola Zagorov BUSINESSNAME (1/dfJerem/romahove): EPIC Compliance Systems DLSIGNA I'FD OPLRA"I'OR PHONE. (888) 700 -EPIC ext. INTI RNA HONAI. CODE: COUNCIL CERTIFICATION NO.: 5264361 — UC ALTERNATE I DESIGNATF,D UST OPERATOR FOR THIS FACT( ATWOntinnnll Update of ICC (ertilication (-Apiration Dams) __ —_ - -_ ___- ______ ____- _ RELATION I O US I F NCII_T I Y (Check One) �i ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® "Third-Paily EXPIRA'fION DA"11 7/12/2009 DESIGNAI'EDOPERAI'ORNAME: Brian Dunahay RELA'T'ION TO US'l FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (If differentfromabove): EPIC Compliance ,Systems DF:SIGNA'1'I D OPERATOR PHONE: (888) 700 -EPIC ext. 1NTERNA'fIONAL CODE COUNCIL CER"1'IF(C AT ION NO.: 8021436 -UC EXI (RATION DAI }. 12/06/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERA"FOR NAME: Al Milburn RELATION I O US I I ACILI FY (('heck One) BUSINISSNAMI.(Ifdifferentfront(,tbove): EPIC Compliance Systems DF.SIGNA ITD OI F RA"FOR PHONE: (888) 700 -EPIC ext. IN 11-1-RNA'FIONAL CODE COUNCIL CERTIFICATION NO.: 0878949 — UC ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DF SIGNA I F D OPI RA`FOR NAME BUSINESS NAME: (l/'chIftrentfrom above): DF.SIGNA'FED OPERATOR PHONE: ( ) ext. --. -- -- IN FERNA'i'IONAL CODF: COUNCIL CLRTIF I('A"IION NO.: ❑ Owner ❑ Operator ❑ P.mployee ❑ Service Technician ® 'I'llird-Party fXPIRA'FION DA'I1 12/6/2010 __.._ RFa.AI'ION 10 11S I I ACILI I Y (Check One) — ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ "Third -Party F,XPIRA"TION DAM--�i 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 (1). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANK OWNER NAME: Beth DePaola TANK OWNER TITLE: Associate Business Management Analyst OWNER PHONE: ( 916) 375-2940 TANK OWNER SIGNATURE: INSTRUCTIONS DATE: 02/13/2009 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.icesafe.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 aocnev jurisdictions and contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.htm1, Contact information for other local agencies within California is available at: www.swrcb.ca.gov/cwphome/ust/contacts/docs/local agency list.xls. 3. 23 C( :R §§'2715(a) requires that you notil), the local agency ofany changes to this information within 30 days of the date of change I'N-062 - 1/1 wwwmnidocs.org 09/22/05