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Mar. 1. 2016 2:18PM RUMEX CONSTRUCTION No,5513 P. 1/2 rZ ie 0 Page 1 of 2 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQ For use by Unidors Member Agencies or where approved by your Local lurisdi TUREu _ I VE Awhority Cited; Title 23, Div. 3. Ch, 16 CalYrbniia Code of Regulations (MR) FACILftY NAME FACILITY PHONE mmil v 1 (U10 Caiifornia Highway Patrol - Stockton ( 209 ) 943-8665 A FACILITY SITE ADDRESS CrrY INOIE �TAL 3330 N. Ad Art Rd. Stockton, CA 95215-22� I,I REASON FOR SUBMITTING THIS FORM (Check one Change of Designated Operator Update of ICC Unification Expiration Date(s) PRIMARY DESIGNATED UST OPEPATOR FOR THIS FAC ELITY DESIONATEDOPERATORNAMPS: Phillip Mendrin RELATION TO UST FACILITY (Check One) [jOwner ❑ Operator ❑ Employee ❑ Service Technician ® Third.PaMr BUSINESS NAME((/'dWerenrfrmaabox): Rumex Construction Corporation BUSINESS NAME (lfdeemiefromabove): Rumex Construction Corporation DESIGNATED OPIRATOR.PHONE: (559) 371-3300 ext. INTERNATIONAL, CODE COUNCIL CERTIFICATION NO.: 5252185 EXPIRATION DATE: 12/15/2016 AL'F ERNATE t DESIONATED UST OPERATOR FOR THIS FACILITY(Oationul) DESIGNATED OPERATOR NAME—, Steve Johnson RELATION TO UST PACILIT'Y (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ service Technician ® Third -Party BUSINESS NAME((/'dWerenrfrmaabox): Rumex Construction Corporation I)ESIGNATEDOP£R.ATORPRONE: (559)271-3300 oxt, INTERNATIONAL CODE COUNCIL CERTIPICATION NO.: 8292272 EXPMATION DATE: 9/26/2016 ALTERNATE 2 DESIGNA'1' 0 UST OPERATOR FOD. THIS FACILITY (optionot) DESIG2 ATED OPERATOR NAME: Robert Steven Carr RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator [] Employee ❑ Service Technician N Third -Party 'BUSINMNAME Wdorcntfromabove): Rumex Construction Corporation DESIGNATED OPERATOR. PHOML (559} 271-3300 ext. INTERNA'T`IONAL CODE COUNCIL CERTIFICATION NO,: 8340716 EXPIRATION DATE: 4/13/2017 ALTERNATE 3 DESIGNATED UST OPERATOR FOR TWS VACMITY (00danuO DESIGNATED OPERATOR NAME: Steven Davis RELATION TO UST FACILITY (Check One) ❑ oar ❑ Operator ❑ EmPloyoe ❑ Service Technician ® Third -Party BUSINMSNAME Wdij}erent)"rw above): Rumex Construction Corporation DESIONAT'ED OPERATOR PHONE: (559)271-3300 ext INTERNATIONAL CODE COiJNr'IL CERTIPICAT ION NO.: 8392256 EXPRATION DATE: 11/10/2017 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). Thee indivldual(s) will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations, Title 23, Sectian 2715(c) through (f). Furthermore, I understand and am in compliance voith the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANK OW RNAI : California Highway Patrol (Beth DePaola) TANK OWNER TITLE: .............-- TANTO CI'Qi M SIGNATf,1RE: /�(.� �. -�-(f GLfi DATE: INSTRUCTIONS 916 ) 843-3800 I. Report the name(s) of the Designated UST Operator(5) as regist(wed with the International Code Council (ICC). ICC certirleation information is available on-line at: www.iccsafe.orgle/certsearch.html. Scamp for "California LIST System Operators. 2. Submit this completed form to the, local agency that regulates this faoility's USTs. Unid'ocs member agency jurisdictions and contact information are listed nn7line at: wvvw.uWdoes.org/membws/whoregulattawhat.htiW. Contact information for other local agencies within Califoraia 1s available at: w*w.swreb ca.gov/cwphome/ttst/coutacts/doesAocal_agency_*t.31s. 3. 23, CCR §2715(a) requires that you notify the local agency of arty changes to this information within 30 days of the date of change. CIiVAd� =tit www_unldpc9 ora; 49127105