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5EP-26-2007 15:59 CITY OF LODI 209 333 6710 P.02 o UNDER . OUND STORAGE TANK SX EM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND 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 City of Lodi, Municipal Service Center (209) 333-6830 FACILITY SITE ADDRESS CITY 1331 S. Ham Lane Lodi, CA. 95242 RFASON FOR SUBMITTING TMS FORM(Check one): Change of Designated Operator Upda<o of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITX RELATION TO UST FACILITY(Check One) DF-SIGNATP,D OPERATORNAME: Dennis Callahan I di rent oM above)' ❑ Owner ® Operator C] Employee BUSINESS NAME(f Ik f' ❑ Service Technician ❑ Tlurd-Party, DESIGNATED OPERATOR PHONE: (209) 333-6800 ext. 2690 INTERNATIONAL CORE COUNCIL CERTIFICATION NO.= -i-004653-UC E7 TION DATE: 12/2Q/2OOS ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY O bona!) RELATION TO UST FACILITY(Check One) DESIGNATED OPF,RATOR NAME: Randy Laney ❑ Owner 0 operator 0 Employee BUSINESS NAME(/f di}Temni from above): D Service Technician ❑ Third-Patty DESIGNATED OPERATOR PHONE: (209) 333-6800 ext. 2684 INTERNATIONACODECOUNCIL CERTIFICATION NO.' 5317552-UC EXPIRATION DATE: 8/21/2009 AL'T'ERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) RELATION TO UST FACILITY(Check Dns) DESIGNATED OPERATOR NAME: ❑ owner ❑ operator ❑ Emptoyee, BUSINESS NAME(Ifd((ferenejrom above): ❑ Servicc Technician ❑ Third-Party DESIGNATED OPERATOR PHONE: ( ) ext EXPIRATION DATE: INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (Opdonal) RELATION TO UST FACILITY(Check One) DESIGNATED OPERATORNAME: ❑ ❑ �� ❑ p Ownerr l~tn loyee BUSINESS NAMP,(If different jrom above): ❑ Service Technician ❑ Third-Party DESIGNATEDOpERATORPHONE: ( ext• EXPIRATION DATE: INTERNATIONAL CODE COUNCIL CERTIFICATION NO-: IFI 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 Furthermore,facility understand oyes training and am in accordance with California Code of Regulations,tlolns23,Section 2715(c)through (f�and local ordinances)applicable to underground storage taoks- in compliance with the requirements(statutes,regal TANK OWNER NAME: City of Lodi (209) 333-6800, TANK OWNER TITLE: Fleet and Facilities Mana er OWNER PHONE: ext. 2690 TANK OWNER SIGNATURE: , DATE: 9/26/07 INSTRUCTIONS I. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council (ICOp. ICC' certification information is available on-line at:www.ieesafe.org/e/certm*reh.htmi. Search for California UST Sys tem2. Submit this completed form to the local agency that regulates facility's r U lateswh:t.html aContac�infornnat on for other ency jurisdictions and contact information are listed on-line at: www.vnidocs.orgJmembers/who local agencies within California is available at:www.swreb.ea.govlcwphometusUcontacts/doe0ocal_agency_listxls. 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. /05 t1N462-1/1 www,onidocr.org TOTAL P.02