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UNDEIROUND STORAGE TANK STEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited.- Title 23,Div. 3, CA 16 California Code of Regulations(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> Manteca Shell (209) 825-7722 <br /> FACILITY SITE ADDRESS CITY <br /> 824 E Yosemite Ave Manteca, CA 95336 <br /> REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Datc(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: Alex Jabbarl RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdterentfmmabove): Norcal Petroleum Services ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (925) 389-1262 ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243897-UC EXPIRATION DATE: 10)2/2008 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY donat) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If wtfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdonat) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(CheckOne) <br /> BUSINESS NAME(/fd�erenrfrom above): El Owner El Operator E] Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdonai) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdif(erentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext ❑ 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 serve 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 (I). Furthermore, I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANKOWNERNAME: <br /> TANKOWNERTITLE: OWNERPHONE• (207 )92Y 77-2 <br /> TANK OWNER SIGNATURE: DATE: /d /Z 3/D <br /> INSTRUCTIONS <br /> 1. Report the name(s)of the Designated UST Operator(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: www.unidoes.org/members/whoregulateswhat.htmi. Contact information for other <br /> local agencies within California is available at:www.SWreb.co.gov/cwphome/usttcontacts/does/local_agency_list.xls. <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 /> UN-062-lit w .unldocs.org 09/22/05 <br />