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UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use b'v Unidocs,Member,agencies or where approved by <br /> v your Local Jurisdiction <br /> Authority Cited: Title 23, Div. 3, Ch. 16 Cali/ornia Code qf*Regzelations(C(71?) <br /> 1 FACILITY NA\IFFAC'IL,I FY PHONE <br /> USA[Tesoro 68152 (209) 368-8787 <br /> FACti-i-rN,SILT ADDRESS CITY <br /> 401 W. Kettleman Lane <br /> Lodi <br /> I LREASON FOR sur3mr-l-TIN6 THIS FORM 'heck one): El Change of Designated Operator Z I 1pdate of[CC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> -1)OPERATOR NAME: Randy Kirby TION T()USTFACHATY(Check One) <br /> DESIGiNAIT, REL,A <br /> BUSINESS NAMI­fdtf Operator [:] Employee <br /> tI, Terentfirom above): US Tanx ❑ Owner <br /> El Service Technician . Z Third-Party <br /> HD OPERATOR PI IONL,: (916) 870-5932 ext. <br /> 1 1 N-I E RN AF 10 NA t_CODE C-Ot t NC-I L CERTIFICATION NO 5250566-Uc i F,"XPIRATIONDATE: 8/28/2010 <br /> ALTERNATE I DESIGNATED LIST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: Jason Kirby RELATION TO USTFACIIATY(Check One) <br /> BUSINESS NAME(11'dt�erentftotn above): US Tanx <br /> I)f-,Sl(iN,,\I-fl)OPI."RA'I'ORPI]ONF�: El Ne(530) 320-6102 ext, Third-Party <br /> IN FERNATIONA1.CODE COUNCIL,CERTIFICATION NO: 5270158-UC EXPIRATION DATE. 9/12/2011 <br /> _J <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNA FED OPERATOR NAME: Nikki Kirby <br /> RELATION TO I.)STFACII-ITY(Check One) <br /> BtJSINI:SSNA%11'(�fflifferent.fi-(.,tp?abot,�e)� USTanx 1:1 Owner 0 Operator El Employee <br /> -hird <br /> NATFL)OPERATORPLIONE, (530) 305-0636 ext. <br /> F—DESK ❑ Service Technician 'I -Party <br /> INTERNATIONAL.CODE COUNCIL,CERTIFICATION NO.: 8018545-UC EXPIRATION DATE: 9/23/2010 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DF.SIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> Ilt S1NFSS NAME Qf(#fPrent"froin above): 0 Owner E] Operator E] Employee <br /> DESIGNATED OPERATOR PIiONE: ext. ❑ Service Technician ❑ Third-Party <br /> INII'RNA'i-IONAI,CODE CO(iNC11,CERTIFICATION No .: EXPIRATION DATF- <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 /> TANK OWNER NAME: Sandy Edwards <br /> TANK OWNER TITLE: Environmental Compliance Administrator OWNER PHONE: (559) 585-8156 <br /> TANK OWNER SIGNATURE: 'Aq L �tc_L DATE: March 4, 2010 <br /> I INSTRUCTIONS <br /> I. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council ([CC). ICC certification <br /> information is available on-line at:www.icesafe.org/c/certsearch.htmi.Search for"California UST System Operators, <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs. Uniclocs 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/does/local_agencv—iist.xis. <br /> 3 <br /> .), 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-III wivw.unidoes.orgg 09/22/05 <br />