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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use b-v L'nidocsMember err r it livre approved b"v'vour Local,furis(liction Authority Cited: Title 23, Dh% 3, Ch 16 C�ilqbrnia Code of Rcaldations(CCR) ----------- --—_--__ ---._—v._------- FACILII'Y NAME FACI L ITY N ION USAfFesoro 68152 (209) 368-8787 -------------------------- ----------- ----------- FACILITY Sll�E,ADDRESS 401 W. Kettlernan Lane Lodi 1 REASON FOR SUBMIT-T fN6'rHfS FORM((heck Op7e1: E] Chaurge of[) siLm,lt..d Operator T pdate oflUCCerlification Expiration Datc(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNA]'ED OPERXI'OR NAME, Randy Kirby RELA11ON'TO US'F FACILYTY(Check One) BUSINESSNAME(tfdifferenfftom above): US 'Tann –1 Oivner D Operzitor f_1 Employee Third-Party —------ 0 Service Fechnician DESIGNAI-I-I'D OPERATOR PHONE: (916) 870-5932 INTERNATIONAL CODE COUNCIL CFR1 IFICAI-ION NO 5250566-UC EXPIRAHONDAY 1: 8/28/2010 - __-----------__ —----- ALTERNATE I DESIGNATED UST OPERATOR FOR THIS EACH, -------------- DF.'SIGNATED OPFRA'I`OR NAME: Jason Kirby RI-1 A'HON-it)I (Check Onc) BUSINESS NAME(1fdfPrent -otnaboiv)� S Tanx 0 Ox�ncr D 01)e-Ltor EEmployee F1 Ser�ic��Tcclmician Third-Party Dt:SIGNAI-1-1)OPI:RAI-()Rf)iIONI; (530) 320-6102 c,�t. IN'FERNA-11ONAL CODE COUNCIL CER 11FICATION NO.. 5270158-UC HFXPIRA' OND,,1]`E: 9/8/2009 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optioned)� DESIGNA'T'ED OPERATOR NAME: Nikki Kirby Rl:LA'I'lON TO I fSTFACILITY(Check One) BUSINESS NANIF(tf,,iifleiepit,fi-oipiab,)vey USTanx E] Owner 00pci<itor ElEmployee ---------- — ------ 76E S IG NA FL 1)OPE RATOR[1 ION F: (530) 305-0636 c\L EScr4 ice'Fcchnican Z Third-Party i INTERNATIONAL CODE COUNCILCER FIFICATION NO: 8018545-UC FX11lRA'l'ION; DA'FG. 9/23/2010 ... ..... ------- ------------- -------- ALTERNATE 3 DESIGNATED LIST OPERATOR FOR THIS FACILITY(optional) DESIGNA'FFD OPERATOR NAML RFLA]'ION F0 t:51 FACI I.rry(Check One) BUSINESS NXNIF(ffdyferenifi�om above) 0 ()\Nn,:.r E] Operator E] Employee ----------------------------- —- ----- Third -P,rt, DE-SICJNA'FI`1*D OPFRA]'OR PHONE: ext, -El Set-%ice'Fechnicimi E]--- -------------- INIERNA,rIONAI.('O[)ECOUN(:[L,C'ERt-il-'[('A,rf()NNO. EXPIRA FION DA I'F.- 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. TANK OWNER NAME: Sandy Edwards TANK OWNER TITLE: Environmental Comp)iance Administrator OWNERP110NE: (559) 585-8156 TANK OWNER SIGNATURE DATI-,.: February 27 2009 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.icesafe.oi-fi/e/certse.ireti.Ittin1.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regUILI(CS this facility's USTs. Ulnidocs member woncy jurisdictions and contact information are listed on-line at: wiviv.uiii(loes.oi-c,/nictiibers/Nvlioreaulateswiiit.littiii. Contact information for other local agencies within California is available at: www.swrcb.ci.cii)N/cwphoitie!ust/co;iticts/does/lociI agency list.xis. 3. 23 CCR §2715(a)re(lL11rCS that VOLI notify the local agency o! am -,hall ges to this ill forillat i oil kt it IT ill 30 da\S fthe date of change. UN-062-1/1 09/22/05