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V 4 OWNER STATEMENTS OF DESIGNATED UST OP TOR AIJ UNDERSTANDING OF ANDCOMPLIANCE WITH UST REQ�f R For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cite& Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) FACILITY NAME FACILITY PHONE Olympian #487 DESIGNATED OPERATOR PHONE: (707) 367-7020 ext. FACILITY SITE ADDRESS CITY 983 Moffat Boulevard Manteca, CA 95336 REASON FOR SUBMITTING MS FORM (Check One): 0 Change of Designated Operator El Update of ICC Certification Expiration Date(s) WIAJOKII Z141A oil ill 11 11131-111" 12115 Igo] W 01 lu 1, , I, - DESIGNATED OPERATOR NAME: MikeZeman RELATION TO UST FACILITY (Check One) E] Owner [:] Operator 0 Employee Z Service Technician Z Third -Party BUSINESS NAME ( Idifferentftomabove): Petro-Techz Environmental Services DESIGNATED OPERATOR PHONE: (707) 367-7020 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5249050 -UC EXPIRATION DATE: 11/15/2010 n4 two 01 D&I Will 9 DI 1111.1l t 12 DE -1401 1 11 V DESIGNATED OPERATOR NAME: -Dan Zeman RELATION TO UST FACILITY (Check One) E] Owner E] Operator E] Employee ED Service Technician 0 Third -Party BUSINESS NAME (If differentfrom above): Petro-Techz Environmental Services DESIGNATED OPERATOR PHONE: (530) 680-2905 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243781-C EXPIRATION DATE: Pending DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) 0 owner El operator 0 Employee [] Service Technician Third -Party BUSINESS NAME (If different from above): DESIGNATED OPERATOR PHONE: ()ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) E] Owner E] Operator F] Employee El Service Technician ❑ Third -Party BUSINESS NAME (Ifdifferentftom above): 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 OWNERNAME: yop A A— A A XOTIMINJIMM TANK OWNER SIGNATURE: DATE: _e2 INSTRUCTIONS I . 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.orgle/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.unidoes.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs/local_pgency_listxls. 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.unidoes.org 09/22/05