Laserfiche WebLink
Nwo, 1%" <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited: Title 23,Div. 3, Ch. 16 California Code of Regulations(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> LDIKCA ( 916 ) 439 - 6042 <br /> FACILITY SITE ADDRESS CITY <br /> 2500 W.Turner Road Lodi <br /> REASON FOR SUBMITTfNG THIS FORM(Check One): ❑✓ Change of Designated Operator ❑ Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> Designated Operator's Name: Philip De Forge Relation to UST Facility(Check One) <br /> BussinessName(Ifeliferentfi•omabove): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (909)594-9850 ❑ Service Technician 0 Third Party <br /> International Code Council Certification#: 8012415-UC Expiration Date: 3/2212014 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> Designated Operator's Name: Leonardo Aguilar lRelation to UST Facility(Check One) <br /> Bossiness Name (If dierent from above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 909 594-9850 ❑ Service Technician ❑' Third Party <br /> International Code Council Certification#: 5302718-UC lExpiration Date: 1/25/2013 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> Designated Operator's Name; Dra an Pesic 111clation to UST Facility(Check One) <br /> Bossiness Name(Ifdii ferentfrom above): SunWest Engineering Constructors,IElOwner ❑ Operator ElEmployee <br /> Designated Operator's Phone#: 909 nc.594-9850 ❑ Service Technician ❑ Third Patty <br /> International Code Council Certification#: 5240928-UC lExpiration Date: 3/30/2014 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(OpHonnl) <br /> Designated Operator's Name: Todd Hansen Relation to UST Facility(Check One) <br /> Bossiness Name(Ifeli ferentfrom above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 909 594-9850 ❑ Service Technician [A Third Party <br /> International Code Council Certification#: 8045710-UC Expiration Date: 11/7/2013 <br /> I 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(c)through(f).Furthermore,I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANKOWNERNAME: `` l/26 !'Z u✓/ 13 LtSS <br /> TANKOWNERTITLE: PHONE: JpU�/ 3006 — C/6 3C, <br /> TANK OWNER SIGNATURE: UA A DATE; fl FJ 2 <br /> INSTRUCTIONS <br /> 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC).ICC certification <br /> information is available on-line at:www.icesafe.org/eteertseareh.html. Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs.Unidocs member agency jurisdictions and <br /> contact information are listed on-line at:www.unidoes.org/members/ivhoregulateswhat.html.Contact information for other <br /> local agencies within California is available at:www.swreb.co.gov/cwphome/ust/contacts/docs/local_agency_list.xls. <br /> 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. <br /> UN-062-1/1 www.unidocs.org 9/22/2005 <br />