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0 0 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 approped by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code ofRegulations (CCR) FACILITY NAME, FACILITY PHONE Chevron 91452 (209) 599-2313 FACILITY SITE ADDRESS CITY 334 E. Main Street Ripon REASON FORST IRMITTIN(? THIS FORM (Cheek One): MchangeofrIesignatedoperator I Ipdate of ICC CeRifiewion Expiration Datc(s) PRmtARV DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: AleXJabbari RELATION TO UST FACILITY (Check Dae) ❑ Owner © Operator ❑ Employee ❑ Service Technician ® Thud -Party BUSINESS NAME Wdjftn mah~): Norcal Petroleum Services, Inc. DESIGNATED OPERATOR PHONE: (925)389-1262. ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243897-U C EXPIRATION DATE: 1012/2008 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Omfonaf) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) 0 Owner ❑ Operator ❑ Employe Q Service Technician ❑ Third -Party BUSINESS NAME (If dj/ferenrfmm about): DESIGNATED OPERATOR PHONE: ( ) ext INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Opdanal) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Chwk One) © Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (tfdzgerentfrom above): DESIGNATED OPERATOR PHONE: ( ) ext 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(a). 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 OR OWNERS AGENT NAME: TANK OWNER OR OWNERS AGENT TITLE: TANK OWNER OR OWNERS AGENT SIGNATURE: STRUCTIONS DATE: -DZ 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.iecsafe.org/e/certsearch.html. Search for "California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidomarg/memberstwhoregulateswbat.html. Contact information for Other local agencies within California is available at: www.swreb.ca.gov/cwphomOnst/contacts/doeWloe&Lagencyjistxls. 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.