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RECEIVED UNDERGROUND STORAGE TANK SYSTEM APR 1 4 2013 OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIItEMEdOAQUIN COUNTY For use by Unidocs Member Agencies or where approved by your Local JurisdictiogNVIRONMENTAL Authority Cited.,Title 23,Div. 3, Ch. 16 California Code of Regulations(CCR)•IEALTH DEPARTMENT FACILITY NAME FACILITY PHONE Lodi CA FO Term Intl ( 9 1 6 ) 4 3 9 - 6 0 4 2 FACILITY SITE ADDRESS CITY 2500 West Turner Road Lodi REASON FOR SUBMITTING TIES FORM(Check One): ❑� Clmnge of Designated Operator El Update of ICC Certification Expiration Datc(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY Designated O erater's Name: Paul McLane Relation to UST Facility(Check One) Bussiness Name(Ifdierentfiont above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Designated O eratoes Phone#: 909)594-9850 ❑ Service Technician M Third Party International Code Council Certification#: 5238651-UC E iratkm Date: 1/24/2015 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY ffiWional) Designated Operator's Name: Leonardo Aguilar Relation to UST Facility(Check One) Bossiness Name(1fdierent fi•oni above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee DesignatedOperator's Phone#: 909 594-9850 ❑ Service Technician M Third Patty International Code Council Certification#: 5302718-UC Expiration Date: 1/23/2015 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Opermoes Name: Ruben Becerra Relation to UST Facility(Check One) Bossiness Name(Ifdfferent from above): SunWest Engineering Constructors,Inc. ❑ owner ❑ Operator ❑ Employee Designated O eratoes Phone#: (909)594-9850 ❑ Service Technician El Third Party International Code Council Certification#: 5307833-UC Ex imtion Date: 1/23/2015 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated O eratoes Name: Pamela Lawrence Relation to UST Facility(Check One) Bussiness Name(Ifdierent front above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (909)594-9850 ❑ Service Technician Third Party International Code Council Certification#: 8078357-UC Expiration Date: 9/612014 I certify that,for the facility indicated at the top of this page,the individuals)listed above will serve as Designated UST Operator(s).Tire 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(1).Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Verizon California,Inc. TANK OWNER TITLE: / OWNERPHONE: AL3 TANK OWNER SIGNATURE: DATE: INSTRUCTIONS 1. Report the name(s)of thesignated UST Operators)as registered with the International Code Council(ICC).ICC certification information is available on-line at:www.iccsafe.org/e/certsearch.html.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/ivhoregnlatemvbat.htmi.Contact information for other local agencies within Califomia is available at:ivvviv.swrcb.ea.gov/ewphome/usVcontacWdoesAocal_ngency_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 of change. UN-062-1/1 www.unidocs.org 9/22/2005