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0 0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Undoes Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited.- Title 23, Div. 3, Ch. 16 California Code ofRegtdariow(CCR) <br /> FACILITY NAME <br /> Valero #3698 FACILITY I83 <br /> (209)) 832-8815 <br /> FACILITY SITE ADDRESS CITY <br /> 153 East 11th Street Tracy, Ca <br /> REASON FOR SUBMITTING THIS FORM(Check One): �Changc of Designated Operator Update of ICC Ceniti n.n Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: Larry Williams RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(ydQemnifromabow): Alpha Petroleum Services, IDC. ❑ Owner ❑ Operator ❑ Em to cc <br /> DESIGNATED OPERATOR PHONE. <br /> (707)678-81 OO ext. ® Service Technician ❑ Thi <br /> rd-Part) <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 55242370-UC EXPIRATION DATE. $/26/2008 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITV(O riots! <br /> DESIGNATED OPERATOR NAME ,John Palest RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(lfdperemfromabo,r): Alpha Petroleum Services, Inc ❑ Owner <br /> ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (707)678-8100 ext. ® Service Technician ❑ Third-Pavy <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5259473-UC EXPIRATION DATE: 10/18/2009 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(1dderenrfromabo,e): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PIIONE: ( 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 QIdperemfrom above); ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( exY ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will sere 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 (Q. Furthermore, 1 understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNER NAME: Valero <br /> TANKOWNERTITLE: Sandy Huff, Compliance Coordinator OWNER PHONE: 559 582-0241 <br /> TANK OWNER SIGNATURE: CZLL DATE: February 14, 2008 <br /> INSTRUCTIONS <br /> I. Report the name(s)of the Designated UST Operalor(s) as registered with the International Code Council (ICC). ICC certification <br /> information is available on-line at:www.iccsafe.org/e/certsearch.html.Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and <br /> contact information are listed on-line at: wtiyw.unidocs.org/members/whoregulateswhat.html. Contact information for other <br /> local agencies within California is available at:www.Swrcb.ca.gov/cwphomc/tist/contacts/docs/local agency_list.xis. <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 /> w'ww.unidocs.ore 09/22/115 <br />