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UNDER ROUND STORAGE TANKS EM An OWNER STATEMENTS OF DESIGNATED UST OPERATOR UNDERSTANDING OF AND COMPLIANCE WITH UST REQtf For use by Unidocs Member Agencies or where approved by your Local Jurisdicti• Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) /T FT FACILITY NAME FACILITY PHONE QCs H & M MARKET- BW # 98 (209) 838-3971 FACILITY SITE ADDRESS CITY 2501 JACKSON AVE. ESCALON, CA. 95320 REASON FOR SUBMITTING THIS FORM (Check One): ❑ Change of Designated Operator ® Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Karen Arnaiz RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (If dierent from above): DESIGNATED OPERATOR PHONE: (209) 518-4836 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5266643 -UC EXPIRATION DATE: 7/16/2009 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (If different from above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (Ifdierentfrom above): DESIGNATED OPERATOR PHONE: ( ) ext. 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) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (If different from above): DESIGNATED OPERATOR PHONE: ( ) ext. 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 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: Bovett Petroleum C/o Rohda Hen TANK OWNER TITLE: Customer $Eir4delQ4ordinator OWNER PHONE: (209) 577-6000 TANK OWNER SIGNATURE: JUyV DATE: August 17, 2007 INSTRUCTIONS 1. Report the name(s) of the Designated UST Operator(s) as registered wi a International Code Council (ICC). ICC certification information is available on-line at: www.iccsafe.org/e/certsearch.htmi. 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 information are listed on-line at: www.unidocs.org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs/local_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. UN -062 -1/1 www.unidocs.org 09/22/05