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r UNDEIv6ROUND STORAGE TANK MTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST For use by Unidocs Member Agencies or where approved toyyour Local � D Authority Cited: Title 23,Div. 3, Ch. 16 California Code ofRegulatio ( - FACILITY NAME FACILITY PHONE NUV 2"9 �o�x Dart Container Corp (209) 333-8088 FACILITY SITE ADDRESS CITY SANJOAQUIN COUNTY 1400 Victor Road Lodi ENVIRONMENTAL HEALTH DEPAHTMENT REASON FOR SUBMITTING THIS FORM(Checkom): 0 Change of Designated Operator Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Thomas Welch RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfrom above): Gettler-Ryan Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925) 551-7555 ext. ® Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8018952-UC EXPIRATION DATE: 8/16/2014 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACHdTY O aonal DESIGNATED OPERATOR NAME: Mike Pratt RELATION TO UST FACILITY(Check One) BUSINESS NAME(If dierentfrom above): Gettler-Ryan Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925) 551-7555 ext. ® Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252315-UC EXPIRATION DATE: 7/12/2013 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Option[) DESIGNATED OPERATOR NAME: ,lose Carrasco RELATION TO UST FACILITY(Check One) 3USINESS NAIvIE(If differentfrom above): Gettler-Ryan Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925) 551-7555 ext. ® Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5322633-UC EXPIRATION DATE: 10/15/2013 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Curls San Nicolas RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdferemfrom above): Gettler-Ryan Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (925) 551_7555 ext. ® Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8120746-UC EXPIRATION DATE: 7/16/2013 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 (1). Furthermore, I understand and am in compliance with the requirements(statutes, regulations,and local ordinances)applicable to underground storage tanks. TANKOWNERNAME: Dart Container Corppy TANK OWNER TITLE: LI OWNER PHONE:^ TANK OWNER SIGNATURE: DATE: 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.htmi. 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/ustleontacts/does/local_agency_list.xts. 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 w .unidocs.org 09/22/05