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05/06/t "10 09:02 FAX 17074466192 TANK-TEK Z003/004 UNDERGROUND STORAGE TANK SYSTEM 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 CRLLC#2705"7 L-A-V 209.478-1522 FACILITY SITE ADDRESS CITY 1469E. HAMMER LANE STOCKTON REASON FOR SUBMITTING THIS FORM(Check One); Change of De.4ignalcd Operator El Update of ICC Certification Expiration Dato(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Daniel Lawrence RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdferentfrom above): Tank-Tek Environmental Corp. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE; (707) "6-6151 ext. ❑ Sorvicc Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.; $025453-UC EXPIRATION DATE; 3/14/2011 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS (FACILITY O dond DESIGNATED OPERATOR NAME; Richard Thomas RELATION 1"0 UST FACILITY(Check one) BUSINESS NAME(tfdJoemmfrom above); Wank-Tek Environmental Corp. ❑ Owner ❑ Operator ❑ Employes DESIGNATED OPERATOR PHONE: (707)446-6151 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO,; 5254736-UC EXPIRATION DATE: 1/20/2011 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPCRATOR NAME; RELATION TO UST FACILITY(Check one) BUSINESS NAME(IjdjBerent from,above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE; ext, ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opttonat) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check one) BUSINESS NAME(Ifdffferentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ❑ Scrvicc Tcchnician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE; I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated (UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations,Title 23, Section 27I5(c) through (f). Furthermore, I understand and am in compliance with the requirements(statutes,regulations,and local O ' ances)applicable to underground storage tanks. TANK OWNER NAME: t V S /�c+l G 77,RMI-F" M 14 R T y�I R N TANK OWNER TITLE: � fJ ' / to OWNER PHONE: 9 299 323$ TANK OWNER SIGNATURE: TE: /2 , /6. U 9 STRUCTIONS t. Report the names)of the Designated UST Operator(s)as registered with the International Code Council(ICC). ICC certification information is available on-line at:www.icesafe.org/e/certseamh.html.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 infarmation are listed on-line at: www.unidoes.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at:www.Swrcb.ca.gov/cwphome/ast/contactstdocsAocal_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. tJN-062-I/I www.unidocs.org 09/22/05