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San Joaquin CountyL <br /> Environmental Health Department <br /> 304 E. Weber Ave., Third Floor Stockton CA 95202 DEC 2 8 2004 <br /> Telephone (209) 468-3420 Fax (209) 468-3433 'EPVIROiVMLjV r <br /> ERMIT/SFpyj'- <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityName:City of Lodi, Municipal Service Center FacilityID#: FA0003961 <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 1331 S. Ham Ln. , Lodi, CA 95242 <br /> X Change of Designated Operator <br /> Facility Phone#: 209 333-6830 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Dennis Callahan Relation to UST Facility(Check One) <br /> Business Name ff di ferent from above): ❑ Owner ❑ Operator E Employee <br /> Designated Operator's Phone#: 209 333-6706 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: XX4141014161 Expiration Date: 12/21/06 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Roger Rich Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator N Employee <br /> Designated Operator's Phone#: 209 333-6830 ❑ Service Technician ❑ Third-Party - - <br /> International Code Council Certification#: XX4141014159 Expiration Date: 12/21/06 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated UST Operator(s). -.The individual(s) will conduct and document monthly <br /> fa,cility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): City of Lodi <br /> SIGNATURE OF TANK OWNER: e Ise: tl <br /> DATE: ��/z��D OWNER'S PHONE#: 209 333-670 <br /> TT <br /> November 2004 <br />