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<br />Authority Cite & Title 23, Div. 3, Ch. 16 Coal tfor nia (70, -le qfRqg ulations
<br />FACILITY PHONE.
<br />PACILI'I'Y NAM F (2ccl 33 H r 3 Z., >'>
<br />Flame Mini Mart
<br />CITY
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<br />FACILITY SITE AI Lodi, CA 95242
<br />1301 W. Kettleman Lane
<br />[I—Updateof 11C" certitnication E,_xpiration Dates)RL,"AS0111 FOR Stj[3MJTTIN6TI IIS FORM (C&ck- One): chanpc of Desi�),natcd Opuator
<br />'16NATED1 US'J'A-WILKA I UK r u 3-1 1 C-4 §0 H't�_
<br />I -I'D O!IFR.A'rOR NAME: Alex Jabbali
<br />-WIMNESS, NAME (ff&ff.,wfim;.br�ae). Nf6rcat Petroleurn Servicest
<br />T)T-,s (925) 389-1262
<br />JGNATFD OPERATOR P"ONE: ext.
<br />897—UC
<br />ALTERNATE i DESIGNATED UST OPERATOR , YUK I III-') VAt-
<br />DESIONATED OPERATOR NAME:
<br />B USINESS NAME (If tkffervinfiroin above):
<br />DE'SIGNATFI) OPERATOR PI iONF: ext.
<br />INTERNATIONAL Ce` DE' COUI 1cu, CEWFIFICATION NO.:
<br />ALTERNATE 2 DESIGNATED U; VR' UrLKA I UK V 4wn k 171101"
<br />DESI 'NATED 01"FRATOR NAME:
<br />F—JIUS—INESS NAME Qfd;,ffervntftorn abore):
<br />DFSIUNATED OPERATOR PHONE:
<br />INTERNATIONAL CODE COUNCIL CERTIFICATION NC).:
<br />ALFERNATE 3 DESIGNATII.;D Uh, I ul'r.AA, OW,11i, 0
<br />�OJIERXYOP NAME'!
<br />IWSINESS NAMF Qfdljlerentfto 0110V4!
<br />DFS16MATEF) OPERATOR PHONE.
<br />I NI FRt'NATIONAL C()1)1, c'()T, C!RT1 FICATION ''10.
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<br />RELATION TO UST VACHTFY One)
<br />E-1 operator El
<br />11 1:ervice Technician 0, Third-llart\
<br />V"NPIRATION DATE: 10/2/2008
<br />RFLATIONTO IJS'I'FA( ILITY (Ched One)
<br />Q owner F1 Operator El Employee
<br />Ej � crvice'l'echniciarl n Third -Party
<br />F.XPIRA'I ION DATE:
<br />RELA"FION TO (Check One)
<br />EJ' O'vvner 0 Operator 0 Employee
<br />C1 Scrvice Technician F-1 Third -Party
<br />EXPIRATION DATF:
<br />RELA I'IONTO USI FACILITY WlleClc "?0
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<br />Owner ❑ Oncrator L
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<br />SerN icc,t7eclIffliciall ❑ Third -]',,1141,
<br />!'�KPIRATION DA F:
<br />I cerfift that, for jhc,
<br />�:,.-'tcd at the j,)p lj--, 4,-j- paueg the
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<br />as ik�sipai' JS,
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<br />e. documient monthly fuiefl:
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<br />TURE:
<br />INSTRUCTIONS
<br />1, the n?'Mc(S) Of Inc OM
<br />is available car -line aa.Search ftbr "Calilciriia US71 'SYstc'
<br />rmation
<br />2'14ys USTs. Unidrcs -cjQmber agrency jurisdictions and.
<br />. this Completed fonp to the local aP ncy that res UIF,;,-,-,.
<br />q niact information i7or oflle-i
<br />isted C' inn at: -
<br />information are lI
<br />juca.l agencies within California is available at:
<br />§t/coat
<br />3. 21 CCR §2715(a) requires that you rfoti' the local a licy of any c-hanges La this inforatmn,�A.,ifhin -30 days oft1he date 0-11 change.
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