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UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Undoes Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited Title 23,Div.3,Ch 16 California Code of Regulations(CCR) <br /> FACBdTYNAME FACILITY PHONE <br /> ARCO LODI ( j <br /> FACILITY SITE ADDRESS CITY <br /> 255 E. HARNEY LANE LODI <br /> REASON FOR SOBMIITINGTTBS FORM(ChrckOne): UChWgcofDcsignatcdOperatm U Update oflOC Certification Eupiratwn Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NA&M- LATHAM ZUBILLAGA RELATION TO UST FACUAY(ChwkOw) <br /> BUSRIESSNAME(Y&f�h—b—Y- TOWN&COUNTRY CONTRACTOR ❑ Oaner ❑ Op aaux ❑ Employee <br /> DESIGNATED OPERATORPHONE: (916)636-9500 Mgt ® Service Technician ❑ Third-Party <br /> WIFRNATIONAL CODE COUNCIL CERTWICATRRINO--: 5275557 EXPIRATIONDAT2 12/13/2014 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACHaTyCoprianaIl <br /> DESIGNATEDOPEPATORNAMe: KELVIN CRUZ RELATION TO USC FACHM(ChwkGm) <br /> eus[NEssNAw(ymfrwfna,ahmV: BZ SERVICE STATION MAINT ❑ ownor ❑ Operator ❑ Employee <br /> DESIGNATEDOPERATOR PHONE: (916)371-2380 ext ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODECOUNCR.C(RITFICAnONNO.: - 8016282-UC EXPIRATIONDAw- 10/28/2013 <br /> ALTF.RIYATE 2 DESIGNATED UST OPERATOR FOR THIS FAC IATY(OptionaD <br /> DESIGNATEDOARATORNAW-. JERAMY CUMMINS RELATION TO UST FAClLnT(Chwk Omi <br /> BUSINESS NAME(7fAfj f—ahmw): BZSERVICE STATION ❑ owner ❑ Operator ❑ Ewioyee <br /> DMIGNATMOPMATORPHONE (916)371-2380 ext ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNGL CERTIFICATION NO.: 80161-UC EXPIRATION DATE- 4/14/2014 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: JAMES WILLIAMS RELATION TO UST FACILITY(CbwkD.) <br /> BUsINEssNAME(ifd0n f—ab­): BZ SERVICE STATION MAINT ❑ ormer ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (916)371-2380 ext. ❑ ServiceTechnician ® Third-Parry <br /> INTERNATIONAL CODE COUNCIL CERTMCATION NO.: 5252274-UC E"IRATIONDATE 6/4/2015 <br /> 1 certify that, for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated UST <br /> Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations,Title 23,Section 2715(x)through(t). Furthermore,I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNERNAME: KENDHARNI <br /> TANK owNER TTTLR: OWNER OWNERFHONE: (916)715-6425 <br /> TANK OWNER SIGNATURE: k:::, ' DATE: <br /> INSTRUCTIONS <br /> 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC).ICC certificatian <br /> information is available on-line at:wwwAcesafe.org/e/cerisearch.htmi-Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs. Undoes member agency jurisdictions and <br /> contact information me listed on-line at: www.undoes.org/membets/whoregLdsteswhathtmi. Contact information for other <br /> local agencies within California is available at:wwwswrcb.ca.gov/cwphometusUcontacts/doesAocal_agenc3_-*t.IIS. <br /> 3. 23 CCR§2715(a)requires that you notify the local agency ofany changes to this information within 30 days of the date of change. <br /> UN 062-Ill www.nnidoraorg 09f22/Os <br />