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UNDERGROUND STORAGE TANK STEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Undoes Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> March & Bianchi Chevron (209)954-0945 <br /> FACILITY SITE ADDRESS CITY Lict. 0 9 2009 <br /> 1916 March Lane Stockton <br /> REASON FOR SUBMITTING THIS FORM(Check One): X Change of Designated Operator LJ Update of ICC Certific <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: James Day RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(1fdi,(jerentfmm above): Mid Valley Consulting & General ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (530) 749-9892 ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8010935-UC EXPIRATION DATE: 5/11/2010 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY onai <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(ifdij(erentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ElService Technician ElThird-party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(ifdiferenifrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. 11Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check Ore) <br /> BUSINESS NAME(ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> El Service Technician ❑ Third-Party <br /> DESIGNATED OPERATOR PHONE: ( ) ext. <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 (f). Furthermore, I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNER NAME: Bhupinder Uppal <br /> TANK OWNER TITLE: OWNER PHONE: 925 413-5501 <br /> TANK OWNER SIGNATURE: 12-- <br /> Z2 <br /> DATE: December 1, 2009 <br /> INSTRUCTIONS <br /> I. 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.icesafe.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/whoregulateswbat.htmi. Contact information for other <br /> local agencies within California is available at: www.swreb.ca.gov/cwphome/usVcontacts/dGes/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 <br /> change. <br /> UN-062-1/1 www.uuidms.org 09/22/05 <br />