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0 4 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited: Title 23,Div. 3, Ch. 16 California Code of Regulations(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> MCI dba Verizon Business (916)373-4603 <br /> FACILITY SITE ADDRESS CITY <br /> 13850 Devries Road Lodi, 95242 <br /> REASON FOR SUBMITTING THIS FORM(Check One): Z Change of Designated Operator 0 Update of ICC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME' Brian Dunahay RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(IfdVerenlfrom above): EPIC Compliance Systems MOwner [] Operator [] Employee <br /> DESIGNATED OPERATOR PHONE: (888) 700-EPIC ext. [3 Service Technician 0 Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8021436-UC EXPIRATION DATE: 112/6/2010 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: Alvin L Milburn RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(1fdifferenifrom above): EPIC Compliance Systems (Downer C3Operator [] Employee <br /> DESIGNATED OPERATOR PHONE-- (888) 700-EPIC ext. E] Service Technician [D Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 0878949- LIC EXPIRATION DATE: 12/6/2010 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(optional) <br /> DESIGNATED OPERATOR NAME: Julian Sherrod RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(1fdolerepilfroin abow): EPIC Compliance Systems DOwner DOperator ClEmployee <br /> DESIGNATED OPERATOR PHONE: (888) 700-EPIC ext. El Service Technician 0 Third-Parry <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8014675-UC EVIRATION DATE: 9/11/2012 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If differentfrom above): ❑ Owner [] Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. ❑ Service Technician ❑ 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) fisted above will serve as Designated UST <br /> Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations,Tide 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 tants. <br /> TANK OWNER NAME: 1;;,JJ Hari") <br /> A <br /> TANK OWNER TITLE: Veqi.2f\t.% ErNy. OWNER PHONE: <br /> TANK OWNER SIGNATURE: DATE: R> <br /> INSTRUCTIONS <br /> 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC). ICC certification <br /> information is available on-line at:vvww.iccsafe.orgle/certsearch.htmL 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 information are listed on-line at: www.unidocs.org/memberstwhoregulateswhat.html. Contact information for other <br /> local agencies within California is available at:www.swreb.ca.gov/cwpbometust/contacts/docs/local—agencyjist.ids. <br /> 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. <br /> UN-062-111 www.unidocs.org 09/22/05 <br />