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ip! SAN JOAQUIN COUNTY ENVIRONEMTAL HEALTH CONNIE MITCHELL UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE PAC BELL dba AT&T CALIFORNIA (UE020) (209) 474-4022 FACILITY SITE ADDRESS CITY 124 W. Elm Street 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 FACILITY DESIGNATED OPERATOR NAME: George Koffel RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdiiferentfrom above): Tait Environmental Services ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (714.)920-5387 ext. ❑ Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5247982-UC EXPIRATION DATE: 12/19/2008 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: See Attachment RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdiiferentfromabove): Tait Environmental Services ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. E] Service Technician ® Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: See Attachment EXPIRATION DATE: See Attachment ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(If dii ferentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑ 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 am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK 01A,NI �R NAM I-,, Steven J Hail I'.I'A N K t AVNl R III t Ia: data EIS&.S (AV1N R Pl[0Nl:: 214-464-3131 1 AIIK i,)tt.'`*lER S1GNA rtlKE: .. `� DAVE: October 31, 2008 INSTRUCTIONS 1. Report the name(s)of the Designated UST Operators)as registered with the International Code Council(ICC).ICC certification information is available on-line at: www.iccsafe.org/e/certsearch.htmi.Search for"California UST System Operators." 2. Submit this completed fonn to the local agency that regulates this facility's USTs.Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at: www.swrcb.ca.gov/cwp home/ust/contacts/docs/local_agency_list.xis. 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. UN-062-1/2 www.unidoes.org 09/22/05