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UNDERGROUND STORAGE TANK SYSTEM <br /> OWNERSTATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE IT UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited.• Title 23, Div, 3, Ch. 16 C'allfornia Code of Regulations(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> C Stop # 5449 (209) <br /> FACII.I'E°Y SITE"s AI?E9RE:5S CITY Stockton <br /> 322 S. Center Pkwy <br /> REASON FOR SUBMITTING THIS FORM(C:heck(Jsre} Change cat'Designated Operator L1 Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME:Altia Fernandez RELATION TO USS`FACILI TY(Check One) <br /> BUSINESS SS NAME(tfdiferenr from above):Convenience Retailers LLC r[I Owner [l Operator Q Employee <br /> DESIGNATED OPERATOR PROW ( 10) 438 - 8849 xt. t_7 Service Technician This-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION No-:4341059940-UC EXPIRATION DATE,12/281201 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FO€i.THIS FACILITY€1 tional <br /> DESIGNATED OPERATOR NAME:Eva Traylor RELATION TO UST FACILITY(Check tine) <br /> BUSINESS NAME Eva Traylor,UST Survey's tr�-ElI Owner [J Operator []Employee <br /> DESIGNA`FDOPERATORPHONE: (909)455-2275 ext. t_l Eervice'r'echnician Q Third-Party <br /> INTERNATIONAL CODE C"OI.NCIL,CERTIFICATION NO,:4341046811-UC EXPIRATION DATE:3122/2013 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED IGN.ATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdi ferent from ahov,�): [I Owner Q Operator E] Employee <br /> DESIGNATE I)OPERATOR PHONE: ( fit ext. Service Technician u Third-Party <br /> INTERNATIONAL.CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3(DESIGNATED UST OPERATOR FOR THIS FACILITY(optional) <br /> EIESIGNATFD OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> AUSIRtESs NAME (tfabove): r[--..I]�� Owner (I operator [3 Employee <br /> DESIGNATED OPERATOR PHONE: ( t_ <br /> ext. Scrvice'Fechnician Third-Party <br /> INTERNATIONAL CODEC"OUNCII:,CERTIFICATION NO: EXPIRATION DATE.: <br /> 1 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 715(c)through (f). Furthermore, I understand and a <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNER NAME, Convenience Retailers LLC / Designee: Allen Faass <br /> TANK OWNER TITLE: Compliance Mgr OWNER PI:IONE; 925 SS4-0800 <br /> TANKCD ER SIGNATURE: f ......� DATE <br /> ..,,w <br /> 1 ! s <br /> INSTRUCTIONS <br /> I. Report the name(s)of the (Designated UST Operator(s)as registered with the International Gude Council(ICC), ICC:certification <br /> information is available tan-line at: iccsafe.orgle/certsearch.htmi,Search for"California UST'System Operators." <br /> 1 Submit th is co repleted form to th e to cat ag ency°that regulates this f acility's USTs;Un idocs m ember ag ency,)urisdictions acrd <br /> contact info r ation are listed tin-tine at: ww,w.unidoes.org/membtrs/whoregulateswhat.htmi.C ontact l nformation for other <br /> local agencies within C:alifomia is available at: swrcb.ca.gov/cwpho a/ust/contacts/doesAocal agency_list xis. <br /> 3. 23 CCR§27I5(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-I/I www.unidoes.org 09/2210 <br />