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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: SBC <br />Facility ID #: LODICA01 <br />Facility Address: 124 W. Elm Street <br />Lodi <br />Reason for Submitting this Form (Check One) <br />® Change of Designated Operator <br />❑ Update Certificate E%Tiration Date <br />Facility Phone #: (209) 943-4128 <br />Designated UST Oaerator(s) for this Facility <br />PRINIARY <br />Designated Operator's Name: George Koffel <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 714.560.8200 <br />International Code Council Certification #: 5247982 -UC <br />Expiration Date: 12/23/06 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Tait Environmental Systems <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 714.560.8200 <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 />❑ 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 Axill <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and annual facilih,- 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). <br />O. <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 A B <br />AT: www.waterboards.ca.2ov/ust/contacts/cuDa aRvs.h 1. zs r*o <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN YS <br />OF THE CHANGE. 00rn 0 t <br />m <br />er 2W4 <br />