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r <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Pac Bell dba AT&T California <br />Facility ID #: LODICA01 <br />Facility Address: 124 W. Elm Street <br />Lodi <br />Reason for Submitting this Form (Check One) <br />0 Change of Designated Operator <br />0 Update Certificate Expiration Date <br />Facility Phone #: (209) 943-4128 <br />Designated UST Operators) for this Facifity <br />PRIMARY <br />Designated Operator's Name: George Koffel <br />Relation to UST Facility (Check One) <br />0 Owner ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third -Party <br />Business Name (If different from above): Tait Environmental Services <br />Designated Operator's Phone #: 714.560.8200 <br />International Code Council Certification #: 5247982 -UC <br />Expiration Date: 12/19/2008 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Tait Environmental Services <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />0 Service Technician 0 Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: See Attached <br />International Code Council Certification #: See Attached <br />Expiration Date: See Attached <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />0 Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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): d ie Khdryan <br />SIGNATURE OF TANK OWNER: <br />DATE: 12/18/2006 / OV?IER'S PHONE #: 214-464-2599 <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/tist/contacts/cupa ag s� html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />