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UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPEC T <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST-REQUIREMENT _ _ <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited Title 23, Div. 3, Ch. 16 California Code of Regulations(CCO R 1 0 201 <br /> FACILITY NAME FACILITY PHONE <br /> C Stop # 5449 (209) <br /> FACILITY SITE ADDRESS CITY <br /> 322 S. Center Pkwy Stockton <br /> REASON FOR SUBMITTING THIS FORM(Check One): [9 Change of Designated Operator Ej Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME:Altia Fernandez RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If different from above):Convenience Retailers LLC ❑ Owner ❑ Operator N Employee <br /> DESIGNATED OPERATOR PHONE: (510) 438 - 8849 xt. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.:4341059940-UC EXPIRATION DATE:12/28/2012 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> I certify that, for the facility indic ated at the top of this page,the individual(s) listed above w ill serve as Designated UST <br /> Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations,Title 23,Section 2715(c)through (f). Furthermore, I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNERNAME: Convenience Retailers LLC / Designee: Allen Faass <br /> TANK OWNER TITLE: Compliance Mgr OWNER PHONE: ( 9 2 5 ) 884-0800 <br /> TANK OWNER SIGNATURE: DATE: <br /> INSTRUCTIONS <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.icesafe.org/e/certsearch.html.Search for"California UST System Operators." <br /> 2. Submit th is cc mpleted form to th a to cal ag ency that regulates this f acility's USTs.Un idocs in ember ag ency j urisdictions an d <br /> contact info rmation are listed on-line at: www.unidocs.org/members/Whoregulateswhat.html.C ontact i nfonnation f or other <br /> local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.xls. <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 /> UN-062-1/1 www.unidocs.org 09/22/05 <br />