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900 '°N N Zl 6106 '6 'lnr quail paAiaaa� <br /> U E GROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATO'ft VED <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMEQ <br /> For Arse by Undoes A9ernher Agencies or where approved by your Local Jurisdiction JUL 0 9 2012 <br /> Authority Cited., Title 23,Div. 3,CA 16 California Code ofRegularions(CCR) <br /> FAC1i.I'I'Y NAME FACILITY PHONE �6'M'17-/8'Er'J'V110ES LT <br /> Country Side Mini Mart (209)948-1684 <br /> FACILITY SITE AU)FX-SS CiTY <br /> 14971 N. Hwy 88 Lodi <br /> REASON FOR SUBMITTING THIS FORM(Check One): Chri F of Dtsipz ted Operator Updarc of ICC Ccrtffieatton Expiration Date(S) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DRSTUNATFD OPERATOR NAME; Alex Jabbati RELA•nON TO UST FACILnY(Cln,k(om) <br /> 2USINESS NAME(00crentftom abave): Nofcal Petroleum Services, Inc ❑ Owner ❑ oparalor ❑ rnployce <br /> DESIGNATED OPERATOR PHONE: (925) 389-1262 ext. ® Service Tedhnidian ❑ Third-Party <br /> IN'rERNAa9ONAL CODE COUNCIL CERTIFICATION NO.; 5243897UC EXPIRATION DATE: 10/2/2012 /0-1-10 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DF310NATED OPERATOR NAMP; RELATION TO UST FACHM(Chrck One) <br /> BIININF-';.S NAMF.(lfdrjferentfrom a0ove); ❑ Owner ❑ Operator ❑ rmpioyee <br /> DESIGNATW OPERATOR PHONE: ( , ext. ❑ Service Tcdhaickn ❑ Murd-P ny <br /> INTERNATIONAL.C013F..COUNCIL,CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY fflomao <br /> INZIGNATED OPERATOR NAME: RMATION TO UST FACILITY(rheck 0m) <br /> BUSINESS N (1fdiffermdfrom ): 13 Owner 0 Operator 0P; ploy <br /> DESIGNATED OPERATOK PHONE: ( ) ext Service Technician Wrd-Pmly CODE COIJNCIL CER:nFiCATION NO.: F.XPiRA11ON DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR TATS FACItLTTY <br /> DFSIU'NATF.D OPERATOR NAME; RELATiON'1.0 U1'T FACILrrY(C:tuckOrm) <br /> BUSINESS NAME(/Ulffarentfrom akw): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Tcchnicum ❑ Tliird-party <br /> INTERNATIONAL CODE COT 11.CERT1F1CAT10N NO.; EXPIRATION DATE: <br /> T 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 co®duct d ocuNnt monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Rego do s.Title 23, Section 2715(e)through(f). Furthermore,l understand and am <br /> in compliance with the requir a (,cram ulations,and local ordinances)applicable to und�Ound storage tankM <br /> TANK OWNER NAME: f ° I� 1 \ -/lYT <br /> TANK OWNER=E: c� �` OWNER PHONE: �� <br /> TANK OWNER SIGNATURE: DATE: — L Z— <br /> IIY�TR[J�TIQNS <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.icesefe.org/e/certscarch.htmi.Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's LISTA. Unidocs member agency jurisdictions and <br /> contact infornwtion aro listod on-line at www.unidocLorg/memberstwboregulatcswbatbtmi,btmi, Contact informaxion for other <br /> local agencies within California is available at:www.swrcb.cm4ov/cwphometusVeontacWdoes/IOCM agency lisLxis. <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 /> Z000/T000 In MISA2IZNIII00 98£9899602 XY3 Ndgz:ZT ZTOZ/60/L <br />