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r <br />f y • <br />• <br />Owner Statements of Designated Undergound Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Nella Oil #427 <br />Facility ID#: <br />Facility Address: 3300 Waterloo Road <br />Stockton, CA 95205 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone: N/A Unmanned Cardlock Facility <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Sutton Thomas <br />Relation to UST Facility (Check One) <br />Business Name (lfdfferent from above) : <br />Nella Oil Company, LLC <br />❑ Owner ❑ Operator Employee <br />❑ Service Technician ❑ Third -Party <br />Designated Operators Phone #: 530-885-0401 ext. 3044 <br />International Code Council Certification #: <br />5232449 -UC <br />Expiration Date: 4/3/2006 <br />ALTERNATE 1 (nntionoll <br />Designated Operator's Name: <br />Barbara Wozniak <br />Relation to UST Facility (Check One) <br />Business Name (Ifdifferent from above) : <br />Nella Oil Company, LLC <br />❑ Owner ❑ Operator Employee <br />❑ Service Technician ❑ Third -Party <br />Designated Operator's Phone #: 530-885-0401 ext. 3059 <br />International Code Council Certification #: <br />5230803 -UC <br />Expiration Date: 3/25/2006 <br />ALTERNATE 2 (nntionall <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />Business Name (Ifdfferent from above) : <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Designated Operators Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve <br />as Designated UST Operator(s). The individual(s) will conduct and document monthly facility <br />inspections and annual facility employee training, in accordance with California Code of Regulations, <br />title 23, section 2715(c) - (f). <br />Furthermore, I understand am in compliance with the requirements (statutes, regulations, and local <br />ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER <br />OR OWNER'S AGENT (Please Print): Barbara Wozniak <br />SIGNATURE OF TANK OWNER <br />OR OWNER`S AGENT (Please Print): �23&V, <br />DATE:/ !� I /6, L / OWNER'S <br />i <br />#: 530-885-0401 ext 3059 <br />el <br />