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0 0 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 23,Div. 3, Ch. 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Mid Ci!y Ca FO Ile ►i ( - - 139 - 6 0 4 2 FACILITY SITE ADDRESS CITY 13850 Devries Road Lodi REASON FOR SUBMITTING TMS FORM(Check Opts) Cltar%c of Designated Operator Update of ICC Certification Expiration Dsto(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY Desi noted'0 rator`s Namo: Paul McLane Relation to UST Facility(Check One) Bussiness Name 0di erent rom above): SunWest Englacering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Doss nateId erator's Phone#: 909 594-9850 ❑ Service Technician ❑ Third Par International Code Council Certification#: 5238651-UC Ex iration Date: 1/24/2015 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(i7 rittrrrrlJ Desi nated O erator's Name: Leonardo A ullar Relation to UST Facility(Check One) Bussiness Name ;T' i erenl rom above): SunWest ineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Desi aced O ratoos Phone#: 909 594-9850 ❑ Service Technician Q Third Part International Code Council Certification#: 5302718-UC Ex nation Date: 1/23/2015 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(t3ptiona Dessi hated C1 eratot's Name; Ruben Becerra Relation to UST Facility(Check One) Bussiness Name I 'i erent roar above SunWest Eu aeeria Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Designated O orator's Phone#: 909 394-9850 ❑ Service Technician [Z Third P International Code Council Certification#: 5307833-UC Expiratlon Date: 1/23/2015 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY( tlnrtt/d) Designated 0 erator's Name: Pamela Lawrence Relation to UST Facility(Check One) Bussiness Name(.1 di ererit ram above): SunWest Ea i eerin _Constructors Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (902)594-9850 ❑ Service Technician Ci Third Part International Code Council Certification#: 8078357-UC Ex iration Date: 9/6/2014 I certify that,for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated UST Operator(s).The Individual(s)will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations,Title 23,Section 2715(c)through(f).Furthermore,I understand and am In compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Verizon Californias Inc. TANK OWNER TITLE: OWNER PHONE: TANK OWNER SIGNATURE: DATE: INSTRUCTIONS 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:www.icesafe.org/e/cei-ftenrcli.html.Search for"California UST System Operators" 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 at:evwty.unidocs.org/membee-sAvhoregulnteswhat.html.Contact information for other local agencies within California is available at:wwiv.swreb.ca.gov/civpllolne/ust/contacts/docs/focal agency_lst.xis. 3. 23 CCR§2715(x)requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN-062- 1/1 www.unldocs.org 9/22/2005