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,' J A UNDERGROUND STORAGE TANK SYSTEM MAY 14 2012 OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTSJ' 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 KINGCA ( 916 ) 439 - 6042 FACILITY SITE ADDRESS CITY 13850 Devries Road Lodi REASON FOR SUBMITTING THIS FORM(Check One): 2 Change of Designated Operator El Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY Designated Operator's Name: Philip De Forge -Relation to UST Facility(Check One) Bussiness Name(If differentfrom above): SunWest Engineering Constructors,Inc. n owner El operator F1 Employee Designated Operator's Phone#: (909)594-9850 [J Service Technician 21 Third Party International Code Council Certification#: 8012415-UC Expiration Date,: 3/22/2014 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Operator's Name: Leonardo Aguilar Relation to UST Facility(Check One) Bussiness Name(-Tfdifferent from above): SunWest Engineering Constructors,Inc. n Owner 0 Operator El Employee Designated Operator's Phone#: (909)594-9850 Ll Service Technician [D Third Party International Code Council Certification#: 5302718-UC Expiration Date: 1/25/2013 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Operator's Name: Dragan Pesic Relation to UST Facility(Check One) Bussiness Name(If different from above): SunWest Engineering Constructors,Inc. El Owner El Operator El Employee Designated Operator's Phone#: (909)594-9850 El Service Technician R] Third Party International Code Council Certification#: 5240928-UC Expiration Date: 3/30/2014 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Operator's Name: Todd Hansen 'Relation to UST Facility(Check One) Bussiness Name(If different from above): SunWest Engineering Constructors,Inc. El Owner 0 Operator El Employee Designated Operator's Phone#: (909)594-9850 Ll Service Technician 21 Third Party International Code Council Certification#: 8045710-UC Expiration Date: 11/7/2013 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: 7 TANK OWNER TITLE: OWNER PHONE: 1,Q450 ;IT TANK OWNER SIGNATURE: fV Zl- 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.iccsafe.org/e/certsearch.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:www.unidoes.org/members/Whoregulateswhat.html.Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/Contacts/docs/Iocal—agencyjist.xls. 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. UN-062-1/1 www.unidocs.org 9/22/2005