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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH RELCEIVED <br /> UNDERGROUND STORAGE TANK SYSTEM OCT 2 2013 <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUI" VRML W_&TH <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction NIT/8EFMCES <br /> Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> PAC BELL dba AT&T CALIFORNIA (UE042) (209)474-4022 <br /> FACILITY SITE ADDRESS CITY <br /> 345 N. San Joaquin St Stockton <br /> REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: George Koffel RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdifferentfromabove): Tait Environmental Services ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (714) 920-5387 ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5247982-UC EXPIRATION DATE: 11/28/2014 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: See Attachment RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdifferentfrom above): Tait Environmental Services ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: See Attachment EXPIRATION DATE: See Attachment <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdii ferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(Ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br /> Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations, Title 23,Section 2715(c) through (f). Furthermore, I understand and am <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. <br /> TANK OWNER NAME: Lynn Hunt <br /> TANK OWNER TITLE: Manager EH&S OWNER PHONE: 214-464-2847 <br /> TANK OWNER SIGNATURE: DATE: September 30, 2013 <br /> INSTRUCTIONS <br /> 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 at: <br /> www.icesafe.org/e/certsearch.htmi.Search for"California UST System Operators." <br /> 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 <br /> at: www.unidoes.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at: <br /> www.swreb.ca.gov/cwphome/ust/contacts/docsAocal_age ncy_list.xls. <br /> 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. <br /> UN-062-1/2 www.unidocs.org 09/22/05 <br />