Laserfiche WebLink
0 <br />UNDERGROUND STORAGE TANK SYSTEM <br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br />UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br />For use lav L/nidocs Member Agencies or where approved by your Local Jurisdiction <br />Authority Cited., Title 23, Div. 3, Ch. 16 California Code (afRegulations (CCR) <br />FACILITY NAML FACILITY PHONE <br />USAfTesoro 68151 (209) 369-1525 <br />FACILITY SITE ADDRESS CITY <br />35 N. Cherokee Lane Lodi <br />REASON FOR SUBMITTING THIS FORM K,heckOne): Change of Designated Operator � Update of ICC Certification Expiration�Date(s) <br />DESIGNATED OPERATOR NAME: Randy Kirby <br />RELATION TO UST FACILITY (Check One) <br />i [:] Owner 0 Operator [I Employee <br />I — <br />Smice Technician Third -Party <br />I Z <br />LJ <br />BUSINESS NAME (tfdifferentftom above): US Tanx <br />DESIGNATED OPERATOR PHONE: (916) 870-5932 ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5250566 -UC <br />EXPIRATION DATE: 8/28/2010 <br />-V,rC <br />--1 1 �V I !II'W ArV 11 1 TQ'r IWPV fATOR, FOR, TV46�_F-Jk. �.�Oqfi*nml) <br />DESIGNATED OPERATOR NAME: Nikki Kirby <br />----------------- <br />RELN11ONTO UST FACILITY (Check One) <br />[] Operator El Employee <br />BUSINESS NAME Itfd(Verentftopn above): US TanxOwner <br />DESIGNATED OPERATOR PHONE: (530) 320-6102 ext. <br />E] Service Technician Third -Party <br />DESIGNATED OPERATOR PHONE (530) 305-0636 ext. <br />INTERNATIONALCODE COUNCIL CERTIFICATION NO.: 8018545 -UC <br />EXPIRATION DATE: 9/23/2010 <br />DESIGNATI-DOPER OPERATOR NAME- Jason Kirby <br />"Jy <br />JocZ� <br />RELATION TO UST FACILITY (Check One) <br />0 Owner F 0 Employee <br />_] Operator <br />El Service `Technician M Third -Party <br />PBUS'I`Nl�_SS �NANirFF(tfdff­,,, f,,, �­ 6 a, �Tan x <br />DESIGNATED OPERATOR PHONE: (530) 320-6102 ext. <br />INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5270158 -UC <br />EXPIRATION DATE: 9/12/2011 <br />ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) <br />DESIGNATED OPERATOR NAME: RELATION J`0 UST FACILITY (Check One) <br />BUSINESS NAME (Ifd(fferentfiront above): El Owner [] Operator [] Employee <br />DESIGNATED OPERATOR PHONE: (I)ext, El Smice'Fechnician F-1 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 4-SiT <br />*perator(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: Sandy Edwards <br />TANK OWNERTITLE: EnvironmentaiC 85-8156 <br />TANK OWNER SIGNATURE ,�� v DATE: February 8, 2010 <br />I INSTRUCTIONS <br />I . Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). [CC certification <br />information is available on-line at: www.iccsafe.org/c/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 <br />contact infon-nation are listed on-line at: www.unidocs.org/members/whoregulateswhat.htmi. Contact information for other <br />local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.xis <br />6 23 CCR 271511 'r, re:omires that ,,on noti[v the local agency of any changes to this information within 30 days of the date of change. <br />UN -062 - 1/1 www.unidocs.org 09/22/05 <br />