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07/13/2007 09 : 51 FAX 17074466192 TANK-TEK 0002/002 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 Authariry Cited: Tide 23, Div, 3, Ch, 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Valero ) FACILITY SITE ADDRESS CITY 2420 Grantline Rd Tracy REASON FOR SUBMITTING T141S FORM(Check One): Z Change of Designated Operator Update of ICC Codification Expiration Dates) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME- LOUIS-Philippe Rooms RELATION TO UST FACILITY(Check One) EUSINESSNAME(lfdifferentfromabove): Tank-Tek Environmental Corp, ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (707) 446-6151 ext. ® Service Technician ❑ Third-Party INTERNATIONAL.COOL COUNCIL CERTIFICATION NO.: 55248336-UC EXPIRATION DATE; 12116/2008 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY O [lona! DESIGNATED OPERATOR NAME: Robert(Rob) Neimeyer RELATION TO UST FACILITY(Check One) BUSINESS NAME Qfd(fferenrfemnabove): Tank-Tek Environmental Corp. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (707) 446-6'15'1 ext. ® Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243067-UC EXPIRATION DATE: 1 212 8/2 00 8 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DSSIGNATEO OPERATOR NAME: RELATION TO UST FACILITY(Chock One) BUSINESS NAME((ldifferenrfrom above): ❑ Owner ❑ Operator ❑ 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 FACR.TTY(Check One) BUSINESS NANM Qfdfferenrfrom 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 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)through (f). Furthermore, I understand and am in compliance with the requirements(statutes, regulations, and local ordinanees) applicable to underground storage tanks. TANK OWNER NAME: / a TANK OWNER TITLE: OWNER PHONE: 2c:•° 73 TANK OWNER SIGNATURE: / f. - DATE: :z / — C Z INSTRUCTIONS 1. 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/certseareh.html. Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Undoes 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/u$Vcontacts/docs/locoi_agencyjist,xls. 3. 23 CCR §2715(a)requires that you notify the local agency of any changes to this information within 30 days of the dare of change. UN•062•lh www.unldacs.org 09/22/05