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UNDE111!CROUND STORAGE TANK SVSTEM 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 Authority Cited.- Title 23, Div. 3, Ch 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE SEP 10 2 March & Bianchi Chevron (209)954-0945 FACILITY SITE ADDRESS CITY ' 1916 March Lane Stockton REASON FOR SUBMITTING THIS FORM(Chest One): Change of Designated Operator x Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: James Day RELATION TO UST FACILITY(Check One) BusINESS NAME W&fferenr.(iwn above): Mid Valley Consulting & General Eng. Owner Operator Employee DESIGNATED OPERATOR PHONE: ( ) 530 749-9892 exL Vice Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 873644-UC EXPIRATION DATE: 6/092014 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Jason Haase RELATION TO UST FACILITY(Check Om) BUSINESS NAME Vfdgerenrfro above): Mid Valley Consulting Owner Operator Employee DESIGNATED OPERATOR PHONE: ( )530 749-8992 exL Service Technician Third-Parry INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8013232-UC EXPIRATION DATE: 03/012013 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdomd) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(If&femnt,fi 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(opdand) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(IfdiferentJrom above): Owner Operator Employee DESIGNATED OPERATOR PHONE: ( ) ext. Service Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 1 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, 1 understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Bhupinder Uppal TANK OWNER TITLE: Owner OWNER PHONE: (925)413-5501 TANK OWNER SIGNATURE: DATE: 07/052012 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.icesafe.org/e%rtwarch.htmi.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.unidoes.org)members/whoregulateswbat.htmi. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/nsUcontacts/doesAocal_agency_IisLxb. 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-062-1/1 www.nnidocs.org 09/22M5