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r 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 City Ca FOReen ( 916 ) 439 - 6042 FACILITY SITE ADDRESS CITY 13850 Devries Road Lodi REASON FOR SUBMITTING THIS FORM(Check One): Q Change of Designated Operator ❑✓ Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY Designated Operator's Name: David Smith Relation to UST Facility(Check One) Bussiness Name(If different from above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (909)594-9850 ❑ Service Technician 0 Third Party International Code Council Certification#: 229013 Expiration Date: 6/7/2016 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Operator's Name: Robert Maddox Relation to UST Facility(Check One) Bussiness Name(If'derent from above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (909)594-9850 ❑ Service Technician 0 Third Party International Code Council Certification#: 224080 Expiration Date: 6/7/2016 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Operator's Name: Kenneth Withee Relation to UST Facility(Check One) Bussiness Name(If different from above): SunWest Engineering Constructors,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (909)594-9850 ❑ Service Technician El Third Party International Code Council Certification#: 8252648 Expiration Date: 3/28/2016 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. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (909)594-9850 ❑ Service Technician Q Third Party International Code Council Certification#: 8045710 Expiration Date: 11/7/2015 1 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 California,Inc. TANK OWNER TITLE: Enviro4,Man#geqWnf, OWNER PHONE: (909)620-5962 TANK OWNER SIGNATURE: DATE: April 8,2014 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.unidocs.org/members/whoregulateswhat.html.Contact information for other local agencies within California is available at:www.swrcb.ca.gov/cwphome/ust/contacts/docs/local agency_list.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