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JUN-15-2009 11:36 FROM:PETRO-TECHZ 8728648 TO:12094683433 P.2 U1 E.RGRO STO G-E 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 Cise-& Title 23, Div, 3, Ch, 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE UPS (209)463-1915 FACILITY SrrE ADDRESS CrrY 1532 North Broadway Stockton, CA 95205 REASON FOR sUBmirn G°PHIS FORM(Check Ore): Change or Designated operators Updato of ICC CertiGeation Expiration Dates) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Dan Zeman RELATION TO UST FACILITY(Check Owe) BUSiNF.SSNAMF.(/fdI erentf wxahave): Petro-Techz Environmental Services ❑ owner Q operator ❑ Employee AF,SIGNATED OPERATOR PHONE: (530)680"2905 ext. Service Technician ® Third-Parry INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5243781-UC EXPIRATION DATE: 3/3/2011 ALTERNATE II DESIGNATED UST OPERATOR FOR THiS FACILITY(D ) DESIGNATED OPERATOR NAME: Mike Zeman RELATION TO UST FACILITY(Check One) BUSINESS NAME(/f dtjjerentfrom above): Petro-Techz Environmental Services ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (707) 367-7020 ext, Lesi Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL.CFRTiFICATION NO,: 5249050-UC IixPiRNI-ION DATE. 11/15/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Ops9tonol) DESIGNATED OPERATOR NAME: Herman Meyer 991.AT1ON TO IJST FACILITY(Check One) BUSINESS NAME(If dfferentfromabove); UPS ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (916) 373-4005 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL.CERTIFICATION NO.: 5288247_UC EXPIRATION mm.: 11/18/2010 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACi LITY(Check one) BUSINESS NAME(b°dprem from above): ❑ Owner ❑ Operator ❑ P-mployce DESIGNATED OPERATOR PHONE: ( , ext_ ❑ Service Technician ❑ 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 Operstor(s). The individual(s)will conduct and document monthly facility inspections and annual raellity employee training in accordance with California Code of Regulations,Title 23,Section 2715(e)through (1). Furthermore,11 understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME:. TANK OWNER TITLE: OWNER PHONE; TANK OWNER SIGNATURE: DATE: INSTR CX ONS 1. Report the narne(s)of the Designated UST Operator(s)as registered with the International Code Council(TCC). ICC certification information is available on-line at:www.iccsafe.org/c/certsearch.html_Search for"California t1ST 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.unidt>mnablmembers/whomlulatecwhat.html. Contact information for other local agencies within California is available at:www,awreb.co.gov/cwphome/ast/contacti/doe al Agency_lisLxis. 3. 23 CCR§271 S(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change, UN4162-t/t www.unidec&ora 09/220