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UNDERGROUND STORAGE TANK SYSTEM ONVNER STATE OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jw*diction Audwrity Cited.- ?Yale 23, Div. 3, Ch. 16 Cal(lornia Code of Regulations (CCR) ItACILITY NAMB FACILITY PHONE Mkt City Ca FO R (916)439-6042 FACILITY SITE ADDRESS CITY 13850 Devries Road Lodi 1EASON FOR SUBMTIMO THIS FORM(Med onBj: 91 Clump oflieel Operator RUpdate of ICC Cmtlfttlon Bxplm ioa Da*9) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACH,ITY D s Name: PliffigDeforse I Relation to UST Facility (Check One) Bossiness Name ffd j&LWm above : SunWest e!ft Constructors, Int: ❑Owner ❑Operator ❑Employee Deo OperaWa Phone #: M 594-9850 , ❑ Service Tadmician d Third Euty international Code CounellCartificslion #: 801241E -UC __ Expiration Data: 3A2/2014 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACHJrY {Optia ran Des! O r'a Name: Leonardo AEla Relation to UST Facility (Check One) Bossiness Name d m above : SSawlWest E Constra Ins. ❑Owner ❑Operator ❑ Employee D Operator's Name: Drs au Paste Relation to UST Facility (Check One) ❑Owner ❑Operator ❑ Employee ❑ Service Technician ❑ Third P Bossiness Name d nr above : 13twWeat EffLn!ffA Coutmiors, Iac. Desi O tar's Phone #: 909 `594.9850 ❑ Service Technician 0 Third hution Date: 3/30/2014 Desi is Phone #: 909 594-9850 International Code Council Certification ,#: 5302718 -UC 'on Date: 1/25/2013 D Operator's Name: Drs au Paste Relation to UST Facility (Check One) ❑Owner ❑Operator ❑ Employee ❑ Service Technician ❑ Third P Bossiness Name d nr above : 13twWeat EffLn!ffA Coutmiors, Iac. Desi O tar's Phone #: 909 `594.9850 International Code Council Certification #:. 52+10928 -UC hution Date: 3/30/2014 V.111_0 *,1 :, t`` F -j CcVry V A N I M to)D1FIN Designated eratofs Name: Todd Hansen Relation to UST Facility (Check One) ❑ Owner ❑ Operator ] Employee C1 Service Teohnioian R1 Third Party Bussiness Name ffdtftrentfrom above : SuaWest EgLeerlo Constructors, Inc. Designated Operator's Phone #: 909 594-9850 International Code Council Certification #: ' 8045710 -UC Expiration Date: 111712013 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 individuals) 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 (t). Furthermore, l understand and am In compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANK OWNERNAME: Vetlon California, Inc. TANK OWNER TITLE: lb „ , ^ , _ OWNERPHONE: all% 11-T r i ---- TANK OWNER SIGNATURE: XL4d Ver, _DATA: [� Ar� 1 1Z. MSTRUCTIOIys 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.feconfe.org/e/cortsmrcLbtmi. Search for "California UST System Operators!' 2. Submit this completed fohn to the local agency that regulates this facility's USTs. Uoldocs member agency jurisdictions and contact information are listed on-line at: www.unidecoorgfmcinbers/whoreplateswbat.btml. Contact information for other Iocal agencies within California is available at: www.swreb.ca.gov/cwphome/owcontacti/does/locaLligeucy_jbtxlL bt.xlL 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, Uri -062 -111 www.unidocs.org 9/2212005