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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 LWdocs 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 LDIKCA ( 9 1 6 ) 439 - 6042 FACILITY SITE ADDRESS CITY 2500 W.Turner Road Lodi REASON FOR SUBMfFIiNG TH6S FORM(Check One): ❑ Change ofoesignated Operator ❑ Update of ICC Certification Expiration Dale(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY Designated Operator's Name: Philip De Forge Relation to UST Facility(Check One) Bossiness Name(Ifdeerentfrom above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee DesiOperator's Phone#: 909)594-9850 ❑ Service Technician M Third Party International Code Council Certification#: 8012415-UC Expiration Date: 3/25/2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Operatoes Name. Leonardo Aguilar Relation to UST Facility(Check One) Bussiness Name d' erentfrom above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (909)594-9850 ❑ service Technician ❑' Third Party International Code Council Certification#: 5302718-UC Expiration Date: 1/25/2013 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated tots Name: Luis Navarro Relation to UST Facility(Check One) Bossiness Name(Ifdifferentfrom above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator [] Employee Designated Operatoes Phone#: (909)594-9850 ❑ Service Technician ❑� Third Party •ntemational Code Council Certification#: 5262210-UC Expiration Dats: 1/272013 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DesignatedOperator's Name: Todd Hansen Relation to UST Facility(Check One) Burssiness Name(Ifdierent from above): SanWest Enginceriag Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee DesignatedOperator's Phone#: 909 594-9850 ❑ Service Technician 0 Third Partv International Code Council Certification#: 8045710-UC Expiration Date: 11/72013 I certify that,for the facility indicated at the top of this page,the IndividnaI(s)listed above will serve as Designated UST Operstor(s).The individual(s)will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations,Titte 23,Section 2715(c)through(t).Furthermore,I understand and am is compliance with the requirements(statutes, egulations,and local or 'maces)applicable to underground storage tanks. TANKOWNERNAME: r / TANK OWNER TITLE: OWNER PHONE: C/ TANK OWNER SIGNATURE: DATE: INSTRUCTIONS 1. Report the name(s)of the Desi /USTperators)as registered with the International Code Council(ICC).ICC certification information is available on-line at:wwwrcesafe.org(e/certsearch.htnrl.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs.Undoes member agency jurisdictions and contact information are listed on-line at www.umidecs.org/members/whoregulattiW�st. t3o tact info ooli fli er local agencies within California is available at:www.swrcb.ca.gov/cwphomehrst/ n�aat s� l_a$em s€ 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this orrhanon within'30'days of me date of change. UN-062-1/1 www.unidocs.org APR 2 5 2012 922/2005 SPK JOP.OUIid COUNTY LW inONMENTAL HEALTH DEPARTMENT