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San Joaquin County Environmental Health Department 304 E. Weber Ave.,Third Floor Stockton CA 95202 Telephone(209)4683420 Fax(209)465-3433 Owner Statements of Designated I.)ndergro>Ind Storage Tank (UST) Operator and Understanding of and Compliance With UST Re'tinirl�.z��cnts -a ` Facility Name:Valle Pacific-Lodi Facility ID#l: N-2658-1-2 Y —_ ---_------ — _ Facility Address: Reason for Submitting this Foran(C'heck One) 633A East Victor Rd.,Lodi,CA 95240 — Change of Designated Operator Facility Phone;=:(209)367-1795 ❑ Update Certificate Expiration Datc Designated UST npel-ator(s)for this Facility PREMARY Designated Operator's Name: Robert Robertson -- Relation to UST Facility(C'lteck me) -! Business Name(If different fir,nt above): Valley Pacific Petroleum Svcs, In .❑ Owner ❑ Operator Employee Designated Operator's Phone 8(209)327-8995— ❑ Service Technician ❑ 'Third-Party International Code Council Certification lkOK00054 --_ - - Expiration Date- _----_ ALTERNA'rE I (Options!) ------- —-- --- - - — Designated Operator's Na1114)lacie Eaker Relation to I lS•r Farility(Chick One) Business Name(Ifdii firenr fio n sbo"Valley Pacific Petroleum Svcs, Inc. ❑ Owner ❑ Operator L'mployce Designated Operator's Phone tl(805)878-8859 ❑ Service Technician ❑ Third-Party International Cote Council C:cruncation 11:EAK00016 Expiration Date: ALTERNATE 2 (Optional Designated Operator's Manic: Relation to UST Facility(Check One) Business Name(If different fionr above) - ---_-_- ^- —-- ❑ Owner ❑ Operator C] Employee Designated Operator's Phone Il: ❑ Service Technician ❑ 7lhird-Party Intcrnalional Code Council Certification it Expiration Date: NOTE:T]IE LO CAI,RFGULATORY AGENCY MUST 13L NOTIFIED OF ANY CHANGES TO THIS INFOWNIATION WITHIN 30 DAA *S OF THE CHANGE. 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 aiid annual facility cinployee training, in accordance with California Code of Regulations, title 23, section 2715(c) -(f). Furtliermore,I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK ON"Y'i!'ER(Please Print): Dal eine _ S.GNA"I'UWE 0F`1'^,NW ONN.NFR— DAVIT,: 12/29/2004 OWNER'S P1 TONE#: (209)948-9412 November 2004 Valley Pacific-Lodi.max