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UNDE11GROUND STORAGE TANK SISTEM RECD v ED OWNER STATEMENTS OF DESIGNATED UST OPERATOR W 2 0 1U10 UNDERSTANDING OF AND COMPLIANCE WITH UST REQU#WMg1 HtALTH For use by Unidocs Member Agencies or where approved by your Local Jurisdiction PERMIT/SERVICES RVICES Authority Cited: Title 23,Div. 3, Ch. 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Pacific Gas and Electric Co.-Stockton SC (209) 942-1400 FACILITY SITE ADDRESS CITY 4040 West Lane Stockton 95204 REASON FOR SUBMITTING THIS FORM(Check One): Z Change of Designated Operator Update of ICC Certification Expiration Date(S) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: R odney Alexander Steele RELATION TO UST FACILITY(Check One) BUSINESS NAME(1fdierentfrom above): ❑ Owner ® Operator ❑ Employee DESIGNATED OPERATOR PHONE: (209) 337-8902 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8072778 EXPIRATION DATE: 6/16/2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Odierentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferenifrom 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(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifjerenifrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ElService Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 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: Des Bell TANKOWNERTITLE: Sr. Vice President, Shared Services OWNER PHONE: (415) 973-4545 TANK OWNER SIGNATURE: DATE: 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.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.unidocs.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.swreb.ca.gov/cwphome/ust/contacts/does/local_agency_list.xis. 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