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03/04/2008 17:22 FAX 17074466192 TANK-TEK <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMK <br />For use by Unidocs Member Agencies or where approved by your Local Jurisdiction / <br />Authority Cited: Title 23, Div, 3. Ch. 16 California Code of Regulations (CCR) <br />FACILITY KALME <br />Exxon <br />FACIL)TY SITE ADDRESS <br />1399 E. Yosemite Ave <br />FACILITY PHONE <br />CITY <br />Manteca <br />REASON FOR SUBMITTING TRIS FORM (Check One); 2 Change ofDesionated Operator <br />PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br />DESIGNATED OPERATOR NAME: Louis-Philippe Rooms <br />Undatc of <br />$USINESS NAME (Ifdifferentfrom above): Tank -Tek Environmental Corp. 1 <br />AESIGNATED OPERATOR PHONE: (707) 446.61 S1 ext. <br />INTL'RNATIONAL Colli COUNCIL CER'f1F1CRTION NO.' 5248336 -UC <br />ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY <br />DESIGNATED OPERATOR NAME: Robert (ROI]) NeirnOy Or <br />BUSINESS NA -MS (/fdoerentfrom above); Tank -Tek Environmental C p. <br />DESIGNATED OMRATOR PHONE; (707)446-6151 ext. <br />INTERNATIONAL CODE COUNCI, CERTIFICATION NO, 5248067-U <br />ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS ACILITY <br />DES IONATED OPERATOR NAME <br />BUSINESS NAME ({jdferent from above); <br />DESIGNATED OPEKATOR PHONE: ) ext. <br />INTERNATIONAL CODE COUNCIL CERTMCATION NO.: <br />ALTERNATE 3 DESIGNATED UST OPERATOR <br />DESIGNATED OPERATOR NAME. - <br />BUSINESS NAME (1fdierenifromabove). <br />DESIGNATED OPERATOR PHONH; ( ) <br />INTERNATIONAL CODE COUNCIL CERTIFICATION <br />THIS FACILITY <br />12003/003 <br />Certification Expiration Date(s) <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />® Service Technician ❑ Third -Party <br />EXPIRATION DATE; 12/16/2008 <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />® Serviec Tcchnician Third -Party <br />EXPIRATION DATE' 12/28/2008 <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />EXPIRATION DATE: <br />RELATION TO UST FACILITY (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />eXT ❑ Service Technician ❑ Third -Parry <br />EXPIRATION DATE; <br />I certify that, for the facility indicated the top of this page, the individual(s) listed above will serve as Designated UST <br />Operator(s). The individual(s) will con uct and document monthly facility inspections and annual facility employee training <br />in accordance with California Code ;�t*al <br />egulations, Title 23, Section 2715(c) through (f). Furthermore, I understand and am <br />in compliance with the requirement utes, regulations, and local ordinances) applicable to underground storage tanks, <br />TANK OWNER NAME: _1C:.' S�T "k.. <br />TANK OWNER TITLE: f > -' ' i" ! t. •= <br />TANK OWNER SIGNATURE <br />I <br />INSTRUCTIONS <br />OWNER PRONE: (•:/ c.,9 ) 6(t n 7U'f"L <br />DATE: I I „ .` .. <br />I. Report the name(s) of Designa-ed UST Operator(s) as registered with the International Code Council (ICC). ICC certification <br />information is available on-line at: www.icesafe.org/e/certsearch.htmi, Search for "California UST System Operators." <br />2. Submit this complete form to the Iocal agency that regulates this facility's USTS. Unidocs member agency jurisdictions and <br />contact information are listed on-line at: www,unidoes.org/members/wharegulateswhathtmi. Contact information for other <br />local agencies within California is available at: www,swrcb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.xis, <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. U1 WWW.Unldocs.org 0922105 <br />