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SYSTEMUNDERGROUND STORAGE TANK OWNER STATEMENTS OF DESIGNATED UST OPERATOR Al� UNDERSTANDING OF AND COMPLIANCE REQUIREM&S 201 4 For use by Unidocs Member Agencies or where approved by your Local Jurisdiction "J authority Cite• Title 23, Div. 3, Ch. 16 California Code of Re lations(CCR) FACILITY NAME FACILITY PHONE USA/Tesoro 68152 (209) 368-8787 FACILITY SITE ADDRESS CHT 401 W. Kettleman Lane Lodi REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS ACII DESIGNATED OPERATOR NAME: Randy Kirby RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferenrfromabo ): US Tanx Owner E3 Operator ❑ Employee DESIGNATED OPERATOR PHONE: (916) 870-5932 ext. Service Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5250566-UC EXPIRATION DATE: 6/30/2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NE: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdif`erent frabove): El Owner ❑ Operator El 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(Ifdii erent from above): 0 Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. Service Technician Third-Party INTERNATIONAL.CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfromabove): ❑ Owner El Operator Employee DESIGNATED OPERATOR PHONE: ( ) ext. El Service Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION 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(c)through (f). Furthermore,I understand and a in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Sandy Edwards TANK OWNER TITLE; Environmental Compliance Administrator OWNER PHONE: 55 585-8156 TANK OWNER SIGNATU DATE: April 26, 2011 INSTRUCTIONS 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 t:www.iccssfe.org/e/certsearch.htmi.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidOCLorg/members/whoregulateswbaLhtmi. Contact information for other local agencies within California is available at: w .src .ca. ov/cwphome/ust/contacts/docs/local_agency_list.xls. 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. t;N-062-I/I www.unidocs.org 09/22/05