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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH * RECEIVED MAY 0 2 2011 UNDERGROUND STORAGE TANK SYSTEM ENrnL HM111 OWNER STATEMENTS OF DESIGNATED UST OPERATOR Mrrr/SEWCES 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 AT&T CORP (UE231) (209) 474-4019 FACILITY SITE ADDRESS CITY J110 W. Turner Rd. Lodi REASON FOR SUBMITTING THIS FORM (Check One): ® Change of Designated Operator ❑ Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Slane Flores RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (Ifdifferent.from above): Service Station Systems DESIGNATED OPERATOR PHONE: (408) 223-6814 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 55249001 -UC EXPIRATION DATE: 4/5/2013 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Ryan Casey RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party BUSINESS NAME (If differentfrom above): Service Station Systems DESIGNATED OPERATOR PHONE: (916) 826-3084 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 80557555'54 -UC EXPIRATION DATE: 9/15/2012 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: David Thomas RELATION TO UST FACILITY (Check One) ❑ Owner E]Operator ❑ Employee E] Service Technician ® Third -Party BUSINESS NAME Qfdifferent.from above): Service Station SyStemS DESIGNATED OPERATOR PHONE: (408) 971-2445 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 7/2/2012 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party BUSINESS NAME (If different from above): DESIGNATED OPERATOR PHONE: ( ) ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: 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, 1 understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANK OWNER NAME: Steven J Hall TANK OWNER TITLE: Manager EH&S TANK OWNER SIGNATURE: INSTRUCTIONS OWNER PHONE: 214-464-3131 DATE: ADril28.2011 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/certsearch.htrul. 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 -1A www.unidoes.org 09/22/05