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Owner Statements otesignated Underground Storage'Pank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name:Plaza Liquors#I Facility ID#: Facility Address:800 Cherokee Lane Reason for Submitting this Forth(Check One) Lodi, CA 95240 Facility Phone#: X Change of Designated Operator Update Certificate Expiration Date Designated UST Operator(s)for this FaeilitY PRIMARY Designated Operator's Name:Alex Jabbari Relation to UST Facility(Check One) Business Name(Ifdifferentfrom above):Norcal Petroleum Service Inc ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: 925-389-1262 X Service Technician ❑ Third-Party International Code Council Certification#:5243897-UC Expiration Date:10/02/2012 l0'6-/Y ALTERNATE 1 donal Designated Operator's Name: Relation to UST Facility(Check One) Business Name(1fdifferent from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name Qfdijjerentfrom above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: I certify that, for the facility indicated at the top of this page,the individual(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) - (f). Furthermore,I understand and am in compliance with the requirements at'ios and local ordinances) applicable to underground storage tanks. m , , Y I'Luatit9 R NAME OF TANK OWNER(Please Print):_ SIGNATURE OF TANK OWNER: Qq q tN6iRONMMAR 14 2012 DATE: 2- /S1 f ?-OWNER'S PHONE#: �" / 9 3 / I H / �N NOAOM ENTALTAL 1-1EALTH DEPARTI;ENT NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/cupa agvs.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.