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05/09/2008 11;40 FAX UND GROUND STORAGE TANK SOfEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidoes Member Agencies or where approved by your.Local Jurisdiction Authority Cited- Title 23, Div, 3, Cit. /6 California Code of Regulations(CCR) FACILITY NA1VifJ FACILITY PHONE Rai Gas Stations, Inc dba Thornton 76 (209)4788959 PACIIATY SI•I'i:ADDRESS CITY 8606 Thomton Road Stockton REASON FOR SUAM171NO THIS FORM(Check Onr-); Change of Designated Operator Update of ICC Certification F,xpiration Dates) PRIMARY DESIGNATED UST OPERATOR FOR THiS FACILITY DFSIONATED OPERATOR NAME: Eric Wayne Gar cla RELATION TO UST FACILITY(Check One) BUSINEsS NAME(I dtf-erent.f vmabove); GDF Solutions, Inc. ❑ 0"er ❑ apmtor ❑ 8mployee 0SSIGNATIhE!�D OPERATOR PHONE! (925)292-0821 ext. E7 service T'cchnician ® Third-Patty TNTERTIATIONAL CODE COUNCiL CERTIFICATION NO,; 5094004»UC EXPIRATION DATA„ 11127/2008 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY onal DF9IONATFSO OPERATOR NAME: Ian Hall ` R1s1,ATipN'Pf>UST f FACILITY(Check One) Bl SiNESS NAME:(Ifabove): GDF SOIUtionS, Inc. ❑ Owner ❑ Operator ❑ rmployec DESIGNATFA OPERATOR PHONE: (925)292-0$21 ext. ❑ Service Technician ® ThWr Party INTERNATIONAL CODE COCINC[L CER,riFICATION NO.: 5311539-UC FXPIRATiON DATE, 3/8/2010 ALTERNATE 2 DESiGNATE,D UST OPERATOR FOR THIS FACILITY(Ofriiomal) DESIGNATE;DOPERATORNAME, Ralph Thomas RF1,A7tON TO LIST FACILITY(Check On") BUSINESSNAME(Jfd{8erent,fromabore); GDF SOlutforlS ir1C. ❑ Owner ❑ Operator ❑ rrnployce ScrviccTcchnician Third-Party DESIATEDOP'RPATORPI•IONE; (925) 292-0821 ext, ❑ ty LiN INTF,RNATIONAL CODL-COUNCIL CER7?FICATiON NO.: 8001428-UC F(I'1RATION DATE' 0111012010 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACiL,ITY(Oplional) DP_siGNAiTED OPERATOR NAME: Stacy Hattori RELATION TO UST FACILITY(Clmrkt7na) BUSINESS NAME(if diffr.►enrf ratnabove), GDF Solutions, Inc. ❑ Owner ❑ OpcMtOr ❑ Employee DESIGNATED OPERATOR PHONE: (925)292-0821 ext. ❑ Service Technician Third-.Party iNTERNATIONA1.CODE COUNCILCERTiFiCATiON NO,: 5295258- pXPiRn.TION DATE; 9/22/2008 I 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 Califoraia 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 tames. TANK OWNER NAME: zr4-1 TANK OWNER TTTLE: y�f/y OWNER PHONJ?_( ¢� S 3• �Q. TANK OWNER SiGNATURE: � �� IN�'1"RUC:WNS 1, Report the name(s)of the Designated UST Operator(s)as registered with the Tntemational Code Council (ICC), ICC certification, information is available on-Line at:www.icesafe•org/e/certsearch.btml. Search for"Cali foruia.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 arc listed ort-line at: www.unidomorg/tnemberq/whoregulatesvvhat.btml, Contact information for othcx local agencies within California is available at.www.swrcb.ca.gov/cwphorne/ust/enntacts/docs/local_agency_li$t.xls. 3. 23 CCR§2715(x)requires that you notify the local agency of any changes to this information within 30 days of the d.atc of change. UN-062.1/1 www.iin[docs.org 09/22/05