Laserfiche WebLink
11 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 68351 <br />Facility ID #: <br />Facility Address: 35 N. CHEROKEE LANE <br />LODI, CA 95240-2411 <br />Reason for Submitting this Form (Check One) <br />9 Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209-369-3525 <br />DesigLiated UST O er tars for this FacW <br />Ij111174M M <br />Designated Operator's Name: Jason C Kirby <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ®Third -Parry <br />Business Name (If dierentfronz above): Delta Environmental Consultants, Inc <br />Designated Operator's Phone #: 530 320-6302 <br />International Code Council Certification #: 5270158 -UC <br />Expiration Date: 10/01/2007 <br />Designated Operator's Name: Randall M Kirby <br />Business Name (If d(Ifereni from above): Delta Environmental Consultants, Inc <br />Designated Operator's Phone #: 916-870-5932 <br />International Code Council Certification #: 5250566 -UC <br />ALTERNATE 2 (Optional) <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician N Third -Party <br />Expiration Date: 10/7/2008 <br />Designated Operator's Name: refer to backup document <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (Ifdifjerentfrom above): Delta Environmental Consultants, Inc <br />Designated Operator's Phone #: refer to backup document <br />International Code Council Certification M refer to backup document <br />Expiration Date: refer to backup document <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated <br />UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility <br />employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br />ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): �_, .Ln <br />SIGNATURE OF TANK OWNER: <br />Date: )/a Owner's Phone#:� <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2008. THE LOCAL AGENCY LIST IS AVAILABLE <br />...._..........,.._•_._ AT: httlfhi,\�,\v.waterboards.ca.aov/usUcontacts/ <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />June 2007 <br />