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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 approved by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Rai Gas Stations, Inc., dba Thornton 76 (209) 478-8959 FACILITY SITE ADDRESS CITY 8606 Thornton Road Stockton REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Eric Wayne Garcia RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferenrfromabove): GDF Solutions, Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925) 292-0821 ext. El Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 55094004-UC EXPIRATION DATE: 11/27/2008 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(O tional) DRELATION TO UST FACILITY(Check One) DESIGNATED OPERATOR NAME: David Hinds BUSINESS NAME(Ifdifferenifromabove): GDF Solutions, Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: -4925) 292-0821 ext. ❑ Service Technician ® Third-Party INTERNATIONAL ODE COUNCIL CERTIFICATION NO.: 559552437-UC EXPIRATION DATE: 10/0412008 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Rick Davis RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfromabove): GDF Solutions, Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925) 292-0821 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 52666755-UC EXPIRATION DATE: 08/18/2008 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Stacy Hattori RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfrom above): GDF Solutions, Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925) 292-0821 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5529552558-UC EXPIRATION DATE: 09/22/2008 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 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 NAME: Amar'it Rai TANK OWNER TITLE: Owner/Operator OWNER PHONE: (408) 593-3190 TANK OWNER SIGNATURE:�j17e , �eVt' DATE: '/ / oZ 6-d 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.iccsafe.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.unidoes.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.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. UN-062-1/1 www.unidocs.org 09/22/05