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GROUND STORAGE TANK S E 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 i fA,, Aro /?w /,a ,cu F_L S4LI3/4C Y ;2 D 47- 9 3.2- /3 07 FACILITY SITE ADDRESS CITY A.5 7' 5' ee& Aj - e V 44 ad 84 v,o . S T o c. A A.), .f.4 � REASON FOR SUBMITTING THIS FORM (Check One): N Change of Designated Operator Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACELrFY DESIGNATED OPERATOR NAME: Ei1C Wayne Garcia RELATION TO UST FACILITY (Check One) BUSINESS NM&Qfdifferentfromabove): GDF Solutions, Inc. El Owner El Operator E] Employee El Service Technician ® Third-PartyDESIGNATED OPERATOR PHONE: (925) 756-1210 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5094004-UCi EXPIRATION DATE: 11131 I2OOA ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FAUMI I Y WPM onto DESIGNATED OPERATOR NAME: David Hinds RELATION TO UST FACILITY (Check one) BUSINESS NAME (Ifdifferentfromabove): GDF Solutions, Inc. El owner EJ operator El Employee DESIGNATED OPERATOR PHONE: _( 925) 756_1210 'ext. E3 Service Technician ®Third-P�Y INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5952437-U(i EXPIlZATION DATE: 05/31 /2007 ALTERNATE 2 DESIGNAI'ED Uel urr liAlvrL rvac =n=a rrsa.=a.== _ DESIGNATED OPERATOR NAME: RICK Davis RELATION TO UST FACILITY (Check One) BUSINESS NAME(Ifdifferentfromabove): GDF Solutions, Inc. ❑Owner ❑Operator El Employee DESIGNATED OPERATOR PHONE: (925) 756_1210 ext, El Service Technician ® Third -Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 52666755 -UC EXPIRATION DATE: 08/1 H/2007 - RELATION TO UST FACILITY (Check One) DESIGNATED OPERATOR NAME: ❑ Owner ❑ Operator ❑ Employee BUSINESS NAME (If differentfrom above): Service Technician Thud -Party ❑❑ DESIGNATED OPERATOR PHONE: ) ext 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: �A/ /,ct,.eAliA FGt.EG SZ-- .10,4,4 V /VC, TANK OWNER TITLE: V/ c— E, TANK OWNER SIGNATURE: ESQ oEN'' INSTRUCTIONS OWNER PHONE: `707 3' f 79 "q DATE: //3/0 7 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.htm]. 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/whoregidategwhat.html. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/does/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 - In www.unidoes.org 09/22/05