Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
UNDE ROUND STORAGE TANK SYS rEM <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(CCRJ <br /> FACILITY NAME FACILITY PHONE JUN29 8 2012 <br /> Tesoro/USA 68152 (209) 368-8787 <br /> FACILITY SITE ADDRESS CITY <br /> 401 W. Kettleman Lane Lodi <br /> REASON FOR SUBMITTING 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 NAME: Rand/ Kirby RELATION TO UST FACILITY(Check One) <br /> BUS INESSNAME(Ifdiiferentfromabove): US TanX ❑ Owner ❑ Operator [:] Employee <br /> DESIGNATED OPERATOR PHONE: (916) 870-5932 ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5250566-UC EXPIRATION DATE: 4/23/2014 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(1f different from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(1f different from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <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 27I5(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 /> TANK OWNER NAME: Sandy Edwards <br /> TANK OWNER TITLE: Environmental Compliance Administrator OWNER PHONE: (559) 585-8156 <br /> TANK OWNER SIGNATURE: ) DATE: June 21, 2012 <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.icCSafe.org/e/certsearch.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/whoregulateswhat.htmi. Contact information for other <br /> local agencies within California is available at: www.swrcb.ca.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 09/22/05 <br />