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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:68153 Facility ID#: <br /> Facility Address:2448 W.KETTLEMAN LANE Reason for Submitting this Form(Check Otte) <br /> LODI,CA 95242-4123 ® Change of Designated Operator <br /> Facility Phone#:209-369-3124 ❑ Update Certificate Expiration Date <br /> Designated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Jason C Kirby Relation to UST Facility(Check One) <br /> Business Name(If dri ferent ftrom above):Delta Environmental Consultants,Inc ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:530 320-6102 ❑ Service Technician B Third-Party <br /> International Code Council Certification#:5270158-UC Expiration Date: 10/01/2007 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name:Randall M Kirby Relation to UST Facility(Check One) <br /> Business Name(If dierent front above):Delta Environmental Consultants,Inc ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:916-870-5932 ❑ Service Technician ® Third-Parry <br /> International Code Council Certification#:5250566-UC Expiration Date: 10/7/2008 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) <br /> Business Name(If different f-ont above):Delta Environmental Consultants,Inc ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone M refer to backup document ❑ Service Technician E Third-Party <br /> International Code Council Certification#:refer to backup document Expiration Date:refer to backup document <br /> I certify that,for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated <br /> UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility <br /> employee training,in accordance with California Code of Regulations,title 23,section 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local <br /> ordinances)applicable to underground storage tanks. <br /> � <br /> NAME OF TANK OWNER(Please Print): r\,&� i✓�-�� �� <br /> SIGNATURE OF TANK OWNER: — � A,�-S <br /> Date: 7 U, Owner's Phone#: �Sq IS <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2008.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: htt ://�s����.�vaterhoards.ca�ov/usticontacts% <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> June 2007 <br />