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SEP-10-2009 16:59 CITY OF LODI 209 333 6710 P.04 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidoes 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 City of Lodi, Municipal Service Center (209) 333.6830 FACILITY SITE AI)I)RESS I CITY 1331 S. Ham Lane Lodi, CA. 95242 REASON FOR SUBMITTING THIS FORM(Check One) Change of Designated Operator Update of ICC Certification Txpiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Randy Laney RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifd fferenr from above): ❑ Owner ® Operator ❑ Employee DESIGNATED OPERA'T'OR PFIONE: (209) 333-6800 ext. 2684 ❑ Service Technician ❑ 'Third-Party INTERNATIONAL CODE COUNCIL CL•RTIF[CATION NO.. 5317552-UC EXPIRATION DATE: 8/6/2011 ALTERNATE 1 DESIGNATED UST OPERATOR FOR T141S FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(1jd)fferenefromabove) ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME! RELATION TO UST FACILITY(Check One) BUSINESS NAME(ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR T141S FACILITY(Optional) OPERATOR RELATION TO LIST FACILITY(Check One) DESIGNATED NAME; BUSINESS NAME(If d ferenl from above). ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Parry INTERNATIONAL CODE COUNCIL C13RTIFICATION NO.; EXPIRATION DATE; 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). The 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(e) through (f). )Furthermore, I understand and am in compliance with the requirements(statutes, regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: CI of Lodi (209) 333-6800, TANK OWNER TITLE: Fleet ervices u ervisor OWNER PHONE. ext. 2684 TANK OWNER SIGNATURE: DATE: September 8, 2009 INSTRUCTIQNS 1. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available on-line at: www.iCesafe.org/e/certsearch.htmi. Search for"California UST System Operators." 2_ Submit this completed form to the local agency that regulates this facility's LJSTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhaLhtmi. Contact information for other local agencies within California is available at: www.swrcb.ca.goy/ewphome/ust/contacts/docs/local_agcncy_list.xls. 3. 23 CCR §2715(x)requircS that you notify the local agency of any changes to this information within 30 days of the date of change. LIN-062-1/1 www.unldocs org 09/22/03