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UNDEROUND STORAGE TANK SAEM 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) HEHFA:CILrFYPHONE FAC[LITYNAME 09) 239-2717 Lathrop Gas & Food FACILITY SITE ADDRESS ITY 14800 South Hwy 99 Manteca REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Dates) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY RELATION TO UST FACILITY(Check One) DESIGNATED OPERATORNAME: Anell Chand BUSINESS NAME Uf d8erentfrom above): Owner ❑ Operator ❑ Employee Pinnacle Fuel Compliance Services El Service Technician ® Third-Party DESIGNATED OPERATOR PHONE: (408) 206-9840 ext. 7/11/2010 INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5119959 UC EXPIRATION DATE: ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(2 tional) RELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: Matthew Hasley BUSINESS NAME(If dieremfrom above): Owner ❑ Operator ❑ Employee Pinnacle Fuel Compliance Services E Service Technician ® Third-Party DESIGNATED OPERATOR PHONE: (209) 603-7127 ext. 7/11/2010 INTERNATIONAL CODE COUNCIL CERTffICATION NO.: 5259431 - UC EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY Avitonal) RELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: ❑ Owner ❑ Operator ❑ Employee BUSINESS NAME(Ifdii erentfrom above): ❑ Service Technician ❑ Third-Party DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) RELATION TO UST FACILITY(Check Otte) DESIGNATED OPERATOR NAME: E] Owner E] operator ❑ Employee BUSINESS NAME(If differentfrom above): ❑ Service Technician ❑ Third-Party DESIGNATED OPERATOR PHONE: ( ) ext. EXPIRATION DATE: INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: I certify that, for the facility indicated at the top of this page, the individual(g) listed above will serve as Designated UST raining Operator(s). The individual(s) will conduct and document monthly facility inspections and annul facilI uity employ dee tand am in accordance with California Code of Regulations,Title 23, Section 2715(c) through (t). in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: OWNER PHONE: ( ) TANK OWNER TITLE: DATE: TANK OWNER SIGNATURE: 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/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.unidocs.org/members/wiloregulateswhat.htmi. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/cOnt2cts/doesAocal_agenCyjiSt.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. Pinnacle Fuel Compliance Services,Inc.