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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 /> FACII.IIYNAME FACILITY PHONE <br /> ARCO LODI ( ) <br /> FACILITY SITE ADDRESS CITY <br /> 255 E. HARNEY LANE LODI <br /> REASON FOR SUBMITTING THIS FORM(Check Ola): Cbarrge of Designated Operator Update of ICC Certification Expnation Dam(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: LATHAM ZUBILLAGA RELATION TO UST FACKRY(Check One) <br /> BUSINESSNAME(IfAgeresf—anevr): TOWN &COUNTRY CONTRACTOR ❑ Owng ❑ 0pe-nor ❑ EmPloyoe <br /> DPSIGNATEDOPERATORPHONE: (916)636-9500 e)a, ® Service Technician ❑ Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5275557 ETIRATION DATE: 12/1312014 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY nal <br /> DFSIGNATEDOPERATORNAAM: KELVIN CRUZ RELATION TO UST FACILIIY(Check One) <br /> BUSINFSSNAME(Hd6e�1.abow): BZ SERVICE STATION MAINT 110— ❑ ON"nw ❑ lmnPloyee <br /> DESIGNATED OPERATOR PHONE: (916)371-2380 ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8016282-UC EXPIRATIONDATE: 10/26/2013 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACHdTY(Opgonag <br /> DTSIGIATEDOPERATORNAW-- JERAMYCUMMINS RELATION TO UST FACILI'IY(CMck One) <br /> BUSINESSNAME(Ifdfferenefromabore): BZ SERVICE STATION ❑ Owner ❑ Operator ❑ Employee <br /> DFSIGNATEDOPERATORPHONR (916)371-2380 ext. ❑ Service Technician ® Third-Pany <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8019661-UC MWATION DATE: 4/14/2014 <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACHdTY(Oaionaq <br /> DESIGNATED OPERATOR NAME: JAMES WILLIAMS RELATION TO UST EACH=(Check Ora) <br /> BUSENESSNAMEpfdjFernrfw aba-) BZ SERVICE STATION MAINT ❑ Owner ❑ Operator ❑ Employee <br /> DESIGNATED OPERATOR PHONE: (916)371-2380 ext. ❑ Service Technician ® Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION No.: 5252274-UC EXPIRATIONDATE: 6/4/2015 <br /> 1 certify that, for the facility indicated at the top of this page, the Individual(s) listed above will serve as Designated UST <br /> Operators} The individual(s)will conduct and document monthly facility inspections and annual facility employee training <br /> in accordance with California Code of Regulations,Title 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 tanks. <br /> TANK OWNERNAME: KEN DHARNI <br /> TANKOwNERTrma OWNER OWNER PHONE: (916)715-6425 <br /> TANK OWNER SIGNATURE:,._i(1 ViJ�--, DATE: <br /> INSTRUCTIONS <br /> 1. Report the mantels)of the Designated UST Operators)as registered with the international Code Council(ICC).ICC certification <br /> information is available on-line at:www.icesafe.org/e/certseorcb.htmi.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 fisted on-line at: www.umidocs.org(members/whoregulateswhathtml. Contact information for other <br /> local agencies within California is available at:www.swmb.".gov/c"home/ust/mutacts/docstlocal_agency_iistsls. <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-III www.amidoes.orx 0%2m <br />