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0 0 UNDERGROUND STORAGE TANK SYSTEM 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 ofRegulations(CCR) EPR 26 1.013 FACILITY NAME FACILITY PHONE 313S TRUCK AND AUTO PLAZA 276765 209-368-8100 _ .. uN',4ENf?LyEALTy FACILITY SITE ADDRESS CITY PEF[ohl• b • '-`" 14749 N THORNTON DRIVE LODI REASON FOR SUBMITTING THIS FORM(Check One): N Change of Designated Operator El Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Kevin Watermolen RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferenl from above): Gllbarco Veeder--Root ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: 916-838-6749 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5250470-UC EXPIRATION DATE: 6/16/2014 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: Judith Bowe RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferenifrom above): Gllbarco Veeder-Root ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: 310-467-2529 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5227182-UC EXPIRATION DATE: 1/4/2014 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(If d ffereni from above): Owner ❑ Operator El Employee DESIGNATED OPERATOR PHONE: ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdif(erenrfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: I certify that, for the facility indicated at the top of this page, the iadividual(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 (f). Furthermore, I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: 313S TRUCK AND AUTO PLAZA c/o Gilbarco, Inc. - Mark G. Richardson TANK OWNER TITLE: Owners Authorl nt WNER PHONE: 800-253-8054 TANK OWNER SIGNATURE: DATE: 2/21/2013 INSTRUCTIONS I. 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.iccsafe.org/e/certsearch.html. Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.htmi. 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 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062-1/42 w .unidocaorg 09/22/05