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NOV-5-2010 07:28A FROM: 4640138 P.1'1 R EC""E I'VE D 4) NOV 0 5 2010 OWNER STATEMENTS OF DESIG TED UST OPERATOR AND Authority Cited: Title 23, Div. 3, Ch. 6 Ca, rnia Code of 4egulailons(CCR) I-AC I LITY NAM Iz FACILITY PHONE, GrOW Line Shell FACILITY SITE ADDRESS CITY 2375 West Grant Line Road Tracy QA 95377 P EASON FOR SUBMITTING THIS FORM(Check One): l3changeomesignateo perator E)qpdate of[CC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILIT RELATION TO USTFACILITY(Check One) DESIGNATED OPERATOR NAME: Brian Dunahay I I t BUSINESS NAME(1fdifferentfromabow): EPIC Compliance System. i F-71 Owner 0 Operator C1 Employee Service Technician Third-Party DESIGNATED OPERATOR PHONE: (888)700-EPIC ext. . INTERNATIONAI.CODE,COUNCIL CERTIFICATION NO.: 8021436-uc EXPIRATION DATE: 12/612010 ALTERNATE I DESIGNATED LIST OPERATOR FoRTHIS FAC111TY(Optional) RE'LATION TO UST FACILITY(Check One) DLSIGNATED OPERATOR NAME: Alvin L Milburn Owner (] Operator Employee BUSINESS NAME Qfdifferentfrom above): EPIC Compliance SysteM. 0 Service Technician Third-Party DESIGNATED OPERATOR PHONE; (888) 700-EPIC ext. INTE'RNATiONAL CODE COUNCIL CERTIFICATION NO.: 0878949- UO EXPIRATION DATE: 12/6/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FAC1111TY(Optional) DESIGNATED OPERATOR NAME: RELATION TO us'r FACILITY(Check One) 13USINESS NAME(1fdtfferenifton;above): Owner [] Operator 1`7 Employee DESIGNATED OPERATOR PHONE: Service Technician Third-Party INTERNATIONAL CODE COUNCIL CER I IFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED LIST OPERATOR FOR THIS FACII TY(Optional)i DESIGN ATED OPERATOR NAME: RELATION 1*0 UST FACH,rry(Check One) BUSINESS NAME(ffdifferen1from abovc): owner M Operator Employee DESIGNATED OPERA YOR PHONL: INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE. I certify that, for the facility indicated at the top of this page, t1i ndividual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthl cility inspections and annual facility employee training in accordance with California Code of Regulations,Title 23,Sectio 1715(c)throu4h (f). Furthermore, I understand and am in compliance with the require nts(statutes, regulations,and locA.1 rdinances)ap I 1plicable to underground storage tanks. TANK OWNER TITLE: gWNER PHONE: �� TANK OWNER SIGNATURE: OATE: INSTRUCT S I Report the name(s)of the Designated usT Operator(s)as registered ith the,fritem tional Code Council (ICC), ICC certification 11 information is available on-line at:wwW.iCCSafe.org/c/certsearch.hti 1.Searc I for lalifornia UST Systern Operators. 2. Submit this completed form to the local agency that regulates this cility's UST4. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidoes.org/mCM, s/whoreguist.oswhat.htmi. Contact information for other local agencies within California is available at: www.swreb.ca.gov/p home/ust/codtacts/does/local—agency_list.xls. 3. 23 CCR §2715(a)requires that you notify tile local agency of any ch, les to this infoirmation within 30 days of the date of change.