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12/22/2009 11 :59 FAX 17074466192 TANK-TEK IM003/004 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE W1111 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 92705447 209.478-1522 FACILITY SITE ADDRESS CITY 1469 E. HAMMER LANE STOCKTON REASON FOR S1J3MI1-r1N(5 THIS FORM(Chvvk One): Z Chungc of Designutcd Operator [-] Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Daniel Lawrence RELATION TO UST FACILITY(C."hack One) BUSINESS NAME(1fdtfferentfromabow); Tank-Tek Environmental Corp. El Owner [:1 Operator ❑ Employee DESIGNATED OPERATOR PHONE: (707)446-6151 ext [:] Service Technician Third-Party INTERNATIONAL CODr.COUNCIL CERTIFICATION NO.: 80254534JC EXPIRATION DATE! 3/14/2011 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(optional) DESIGNATED OPERATOR NAME: Richard Thomas RELATION TO UST FACILITY(Check One) SUSINESS NAME(1fdfferentfromabove), Tank-Tek Environmental Corp. (DOwner [3Operator ClEmployee DESIGNATED OPERATOR PHONE: (707)446-6151 W. El Scrvicc Technician Z Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.; 5254736-UC EXPIRATION DATE: 1/20/2011 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAMF(,Vd(reren1from ahove): [I owncr 0 Opmtor 0 Employ.c DESIGNATED OPERATOR PHONE: e 0 Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL,CERTIFICATION NO.; EXPIRATION DATE; ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(1fdifferentfrom above): 0 Owncr [I Operator F1 Employee DESIGNATED OPERATOR PHONE; ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CFRTIFICATTON NO.: EXPIRATION DATE,, T certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator($), 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 ord" ances)applicable to underground storage tanks. TANK OWNER 70RMIG" M14P1TV(fJVhqN TANK OWNER TITLE: C-fi C.AW Pl-/ !aNq dF—,q OWNER PHONE. ( 9 IS)299 323og TANK OWNER SIGNATURE: 12 , 1C. 09 INSTRUCTTONS 1, Report the name(s) of the Designated UST Operator(s)as registered with the International Code Council (TCC). ICC certification information is available on-line at: www.icesife-org/e/certsearch.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 in-formation are listed on-line at: www.unidoes,org/members/whoregulateswhaLhtmi. Contact information for other local agencies within California is available at:www.swreb.ca.gov/cwphome/ust/contacts/does/local-2gency_list.xis. 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 091".2/05