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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Kayo Oil Company Site # 2705447 <br />Facility ID #: <br />Facility Address: 1469 E. Hammer Lane <br />Stockton, CA 95210 <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209478-1522 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Jerry Zimowske <br />Relation to UST Facility (Check One) <br />X Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 510-364-4452 <br />International Code Council Certification #: 5249080 -UC <br />Expiration Date: 12/1/2006 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: See Attached <br />Relation to UST Facility (Check One) <br />X Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: See Attached <br />International Code Council Certification #: See Attached <br />Expiration Date: See Attached <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: See Attached <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician X Third -Party <br />Business Name (If different from above): USTanx <br />Designated Operator's Phone #: 530-268-3949 <br />International Code Council Certification #: See Attached <br />Expiration Date: See Attached <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 <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER <br />OR OWNER'S AGENT (Please Print): Stephen Bold for ConocoPhillips <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: 2/15/2005 OWNER'S PHONE #: <br />San Joaquin County Dept. of Health <br />714-428-6572 <br />September 2004 <br />