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' 1 <br /> Owner Statements of TSesignated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: SBC FacilityID#: LODICA01 <br /> Facility Address: 124 W. Elm Street Reason for Submitting this Form(Check One) <br /> Lodi 0 Change of Designated Operator <br /> Facility Phone#: (209)943-4128 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Tait Environmental Systems Relation to UST Facility(Check One) <br /> Business Name(If di ferent from above): O Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714.560.8200 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: See Attached Expiration Date: See Attached <br /> ALTERNATE 1 O donal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: O Service Technician O Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> I certify that,for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations,title 23, section 2715(c) -(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Irene Sot <br /> SIGNATURE OF TANK OWNER: kh <br /> DATE: 12/15/04 OWNS S PHONE#: 866-492-6836 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.gov/ust/contacts/cupa agys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />