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UNDERGROUND STORAGE TAN, SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WIT# UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by y'pur Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) FACILITY NAME FACILITY PHONE BUSINESS NAME (Irdifferentfrom above):I BZ Service Station Maint., Inc. � DESIGNATED OPERATOR PHONE: (916)371-2380 ext. FACILITY SiTE ADDRESS CiTY t�25�1�� P`�' wDl Grp Sacramento, CA REASON FOR SUBMITTING THIS FORM (Check One): Ll Change of Designated Operator— Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR TUT -4Z Ferri rry DESIGNATED OPERATOR NAME: Jeramy CumminsA�A RELATION TO UST FACILITY (Check One) ❑Owner ❑Operator C1 Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Irdifferentfrom above):I BZ Service Station Maint., Inc. � DESIGNATED OPERATOR PHONE: (916)371-2380 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8019661- UC EXPIRATION DATE: 3I23I2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR T14TR TI Arrr.rTV/nn.t.....rl DESIGNATED OPERATOR NAME: Kelvin Cruz A' - - ..... RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Ifdi(jerentfrornabove): BZ Service Station Maint., Inc. DESIGNATED OPERATOR PHONE: (916) 371-2380 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8016282 UC EXPIRATION DATE: 10/28/2013 IAA. r LKNA i E 2 DES1GNAI ED UST OPERATOR FOR THIS FACILITY /Ontionalli DESIGNATED OPERATOR NAME: Stan Yoder RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Ifdifrerenifromabove): BZ Service Station Maint., inc DESIGNATED OPERATOR PHONE: (916) 371-2380 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5250317 -UC EXPIRATIONDATE: 12-15-2012 t+n.►e.xvvxare,3 r✓e,�rt�urrtl,tll,[J UJl VY�KAt-UK H'UR'1'HIS FA('ii.ITY /nntinden.i DESIGNATED OPERATOR NAME: Rhome Desblens RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee El Service Technician ® Third -Party BUSINESS NAME WdiJ)'erenifromabove): BZ Service Station Mairlt., Inc DESIGNATED OPERATOR PHONE: (9 16) 371-2380 ems, INTERNATIONAL CODE COUNCIL CERTfFICATiON NO.: 5244364 -UC EXPIRATION DATE: 1/2/2012 I certify that, for the facility Indicated at the top of this page, the individuals) :listed above will serve as Designated UST Operstor(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 OWNER NAME:1:A-c'-I. C -- TANK OWNER TiTLE: CV_1t__O*Z-- OWNER PHONE: (74YOl )d iv—o�aj TANK OWNER SiGNATURE:/�`'"^� C)ATE:_ j �t2 I t2 INSTRUCTIONS 1. Report the name(s) of the Designated UST Operator(s) as registered with the Intemgtionai Code Council (ICC). ICC certification information is available on-line at: www.iccsafe.org/e/certsearch.htmi. Search for " .alifornia UST System Operators:' 2. Submit this completed form to the local agency that regulates this facility's UST . Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulat!swhat.htmi. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/cor� taets/does/local agency_listxls. 3. 23 CCR §2715(a) requires that you notify the local agency of any changes to this info mation within 30 days of the date of change. UN -062 -1/1 www.unidocs.org 09R2Po3