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0 * RECEIVED UNDERGROUND STORAGE TANK SYSTEM S E P 12 2Q,13 OWNER STATEMENTS OF DESIGNATED UST OPERATOR AQVIRONMENTAL EAE- DEPARTMENT 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) FACIIXI-f NAME FACILITY PHONE Mid City Ca FO Regen (916 } 439 - 6042 FACILITY SITE-ADDRESS CITY 13850 Devries Road Lodi REASON FOR S1113MMING THIS FORM(Check One): Q Change of Designated Operator R] Update of ICC Certification Expiration Dates) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY Designated Operator's Name: Paul McLane Relation to UST Facility(Check One) Bussiness Name(If different from above): SunWest Engineering Constructors,Inc. [I Owner 0 Operator Ll Employee Designated OELraLoes Phone#: L909 -9850 El Service Technician 21 Third Party J594 International Code Council Certification#: 5239651-UC Expiration Date: 1/24/2015 ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated 2perator's Name: Leonardo Aguilar Relation to UST Facility(Check One) Bussiness Name(Ifdifferentfrom above): SunWest Engineering Constructors,Inc. [:1 Owner El Operator El Employee Desi ted Operator's Phone#: J909)594-9850 El Service Technician R] Third Party International Code Council Certification#: 5302718-UC Ex iration Date: 1/23/2015 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated OLxrator's Name: Ruben Becerra 'Relation to UST Facility(Check One) Bussiness Name(Ifilifferentfrom above): SunWest Engineering Constructors,Inc. El Owner El Operator El Employee Designated Operator's Phone#: (909)594-9850 El Service Technician 21 Third Party International Code Council Certification#: 5307833-UC Expiration Date: 1/23/2015 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) Designated Operator's Name: Pamela Lawrence Relation to UST Facility(Check One) Bussiness Name(If differem ftom above): SunWest Engineering Constructors,Inc. El Owner El Operator Ej Employee Designated Operators,Phone#: 909 594-9850 El Service Technician 21 Third Party International Code Council Certification#: 8078357-UC Expiration Date: 9/6/2014 1 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(t).Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNERNAME: Verizon California,Inc. TANK OWNER TITLE: 1:��IIANJ A m ogt_ OWNER PHONE: I 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:wmv.iccssfe.org/e/cei-tsearch.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.tinidocs.ojT/membersAvboregulatesivhat.html.Contact information for other is local agencies within California is available at:,vv,,v%v.swreb.ca.gov/ctvpbome/ust/contacts/does/local-agencyjist.xls. 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 www.unidocs.org 9/22/2005