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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 MCI dba Verizon Business (916) 373-4603 FACILITY SITE ADDRESS CITY 2551 East Louise Ave Manteca, 95330 REASON FOR SUBMITTING THIS FORM (Check One): Change of Designated Operator Z Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Brian Dunahay RELATION TO UST FACILITY (Check One) ❑ Owner p Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (/fdierentfrom above): EPIC Compliance Systems DESIGNATED OPERATOR PHONE: (888) 700 -EPIC ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8021436 -UC, EXPIRATION DATE: 12/10/2012 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Alvin L Milburn RELATION TO UST FACILITY (Check One) BUSINESS NAME(lfdierentfromabove): EPIC Compliance Systems ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (888)700 -EPIC ext. ❑ Service Technician ®Third -Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 0878949 -UC ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: BUSINESS NAME (1f dierent from above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: BUSINESS NAME (tfdierentfromabove): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 11/12/2012 RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party EXPIRATION DATE: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party 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) appicable to underground storage tants. TANK OWNER NAME. u t r' J TANK OWNER TITLE: 44, 19 r1 A (W. s '1 c,{, j' OWNER PHONE: (fl -11 ) - (+ lhou'AIL" Ime&I 1. Report the narne(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available on-line at: www.iccsafe.org/e/certsearch.hmd. 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.hind. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs4ocal ageney_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 ofchange. UN -062 -1/t www.unidocsorg 09/22/05