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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Un[docs Member Agencies or where approved by your Local Jurisdiction Authority Cited• Title 23,Div.3, Ch. 16CalfforniaCode of Regulations(CCR) PACILTTY NAME Standard Petroleum 140 (Chevro:;ChangeofDesignated FACILITY ,P�HpONE q G FACILITY SITE ADDRESS (�v-r ) • ��—� J 140 Lathrop Road CITY Lathrop REASON FOR SUBMITTING THIS FORM(Check one): Operator Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Terek NaWafd , RELATION TO UST FACILITY(Check one) BUSINESS NAMB(lfdlf/erenJfrom oboveJ: AMIMASSOciateS Inc. DESIGNATED OPERATOR PHONE: ❑ O"m01 ❑ Operator [I Employee (510)220-4233 ❑ ServiceTechnician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8048966-UC EXPIRATION DATE: ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY O tiara! 2/18!2014 DESIGNATEDOPERATORNANIE: Anlei Chand RELATION TO UST FACILITY(Check one) BUSINESS NAMS(lfd�eren' mabove): Pinnacle Fuel Compliance ❑ Owner DESIGNATED OPERATOR PHONE: 171 Operator ❑ Employee INTERNATIONAL (408)206-9840 ext. ❑ ServiceTechnieian ® Third-Party i INTERNATIONAL CODE COUNCIL CBRTIPICATION NO:: " ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Oglonn/) EXPIRATION DATE: 7/16/2012 DESIGNATED pPERATOR NAME: i RELATION TO LIST FACILITY(Cheek one) i BUSIINESS NAME(Ifd�eremfrom aboveJ: DESIGNATED OPERATOR PHONE: ( El Owner ) ❑ Operator 111 Employee ext. ❑ Service Technician ❑ Third-Party MTERNATIONAL CODE COUNCIL CERTIFICATION NO.: ALTERNATE 3 DESIGNA TED UST OPERATOR FOR THIS FACILITY(OpYonn!) EXPIRATION DATE: DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifd(/jerenIfmm above): - DESIGNATED OPERATOR PHONE: ( ) ❑ Owner ❑ Operator ❑ Employee ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: A EXPIRATION DATE; qI I certify that, for the facility indicated at the top of this page, the individuel(a) 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: TANK OWNER TITLE: T+'G5 tale. OWNER PHONE: �IZ57) 196 90( TANK OWNER SIGNATURE: DATE:. z/�,qlI 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/certsearch.htmi-Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unldocs member agency jurisdictions and contact information are listed on-line at: www.unidoes-org/members/whoreguiRtegwhat.htmi. Contact information for other local agencies within California is available at:www.Swreb.ca.gov/ewphome/ust/contacts/docs/local_ageacy_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-ul www.unidomarg _ o9nz/os