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RE7`: sj 4:r <br />Oct 16 2017 02:23PM HP FaxFlag City Cnevron 2093341873 page 2 ,! <br />NG ✓ = 3 M7 <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATbc-/tLTliq <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQ S <br />For use by Unidoes Member Agencies or where approved by your Local Jurisdiction <br />Aulhority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) <br />FACILITY NAME <br />Flag City Chevron <br />FACILITY PHONE <br />(209) 334-1873 <br />FACILITY SITE ADDRESS <br />CITY <br />64.1 Capital Ave <br />Lodi <br />REASON FOR SUBMITTING THIS FORM (Check One): 0 Change of Designated Operator ER Update of ICC Certification Expiration Date(s) <br />PRIMARY nPRIP-N A-rrn 1ri4z-r "V U A'i'flU 10hn mvia n a rte• <br />DESIGNATED OPERATORNAME: Ale)(Jabbarl <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ ServiceTechnician ® Third -Party <br />BUSINESS NAME, Wdeerenlfromabove): Norcal Petroleum Services, Inc <br />DESIGNATED OPERATOR PHONE: (9255) 359-1262 ext, <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243897UC <br />EXPIRATION DATE: 10/3/2018 <br />_­­ ­ I, l L l LL' JIVI%tV A jr," U,3 ■ Vrr,nw r Vlc V VK -1 tux k'ALIL1'f Y(QDfiona1) <br />DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) <br />BUSINESS NAME (lf di,/ferent from above): _ ❑ Owner ❑ Operator ❑ Employee <br />DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ® Third -Party <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.= EXPIRATION DATE: <br />�.. .. U � Lc13►v1_1t% It zx. # U3 VX-ZKA t UK H VK t MIN N'ACr1I UVY (Optional) <br />DESIGNATED OPERATOR NAME: <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Patty <br />BUSINESS NAME (Ifdifferentfrom above): <br />DESIGNATED OPERATOR PHONE: ( ) ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: <br />EXPIRATION DATE: <br />DESIGNATED OPERATOR NANIE: <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner 71 Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />BUSINESS NAME (Ifdifferentfromabove): <br />DESIGNATED OPERATOR PHONE: ( } ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: <br />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 (r). 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; 5 I L S 0 <br />TANK OWNER TITLE: �—r P,6 zt /{� OWNER PHONE: (1`2-1 <br />TANK OWNER SIGNATURE: 7�_)" _"' DA' <br />INSTRUCTIONS <br />I . Report the name(s) of the Designated tST Operator(s) as registered with the International Code Council (1CC). ICC certification <br />information is available on-line at: www.iccssfe.orgle/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.unidoc3.org/members/whoregulateswhat.html. Contact information for other <br />local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/doesAocal_agcncy_list.xls. <br />3. 23 CCR §2715(x) requires that you notify the local agency of any changes to this information within 30 days of the date of change. <br />UN -062 - 1/1 www.unidoes.org 09/22/05 <br />