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SEP-25-2007 17:35 CI OF LODI 209 333 6710 P.05 UNDERGROUND STORAGE TANK SY a rEVI 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 ofRegulations(CC)?) FACILITY NAME FACILITY PHONE City of Lodi, Municipal Service Center (209)333-6830 FACILITY SITE ADDRESS CITY 1331 S. Ham Lane Lodi, CA. 95242 REASON FOR SUBMITTING THIS FORM(Check One): Change of Designated Operator Update of ICC CertificationExpiration Datc(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATORNAME: Dennis Callahan RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferent from above): ❑ Owner ® Operator ❑ Employee DESIGNATED OPERATOR PHONE: (209) 333-6800 ext, 2690 ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: XX4141014161 EXPIRATION DATE: 12/20/2008 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITYLO ~0 DESIGNATED OPERATOR NAME: Randy Lane)/ RELATION TO UST FACILITY(Check One) BUSINESS NAME(ifdifferenr from above): ❑ ow= ® Operator ❑ Employ- DESIGNATED OPERATOR PRONE: (209) 333-6800 ext, 2684 ❑ Service Technician ❑ Third-Party INTFRNATIONAL CODE COUNCIL CERTIFICATION NO.: )()(4141014160 EXPIRATION DATE: 8/21/2009 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(OpdoxBl) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAMF(tfdifferem from above): ❑ Owner ❑ Operator ❑ Employec DESIGNATED OPERATOR PHONE; ( ) ext_ ❑ Ser icc Technician © Third-Patty INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferenr from above): ❑ Ovvncr ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CRRTIFICATION 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, I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: City of Lodi (209) 333-6800, TANK OWNER TITLE: Fleet and Facilities Manager OWNER PHONE: ext. 2690 TANK OWNER SIGNATURE: DATE: September 24, 2007 1NSTRUCTI2I 1S I_ 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:w+ww.kessfe.org/e/certsettrcILhtml.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.unidws.org/memberstwheregulateswhat.html. Contact information for other local agencies within California is available at:www.swrcb.ca.goy/ewphome/,ast/contsketaidoesAocal—a gency_li$t ids. 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. LN-062-1/1 www.uaidoes urg 09/22/05 TOTAL P.05